Pediatric Sedation and Analgesia

1. Pediatric Sedation and Analgesia Jan Chandler RN,MSN, CNS, CPNP

2. PSA • Procedural sedation and analgesia (PSA) refers to the pharmacologic techniques of managing a child’s pain and anxiety.

3. AAP definition 1992 • Referred to as “conscious sedation” • A depressed state of consciousness where the patients were able to retain protective reflexes and “respond appropriately to stimuli”.

4. Procedural Sedation Re-defined • American College of Emergency Physicians re-named “conscious sedation” • Procedural sedation’s goal was to medicate patients until they can tolerate unpleasant procedures • This sedation was termed “moderate sedation”

5. Four Levels of Sedation • JCAHO and American Society of Anesthesiologist described the 4 levels of sedation. • Anxiolysis • Moderate Sedation • Deep Sedation • General Anesthesia

6. Minimal Sedation • Anxiolysis or minimal sedation refers to a drug-induced state in which cognitive and motor function may be impaired.

7. Moderate Sedation • Moderate sedation is a state of moderate sedation in which a child responds purposefully to verbal commands with or without light tactile stimulation.

8. Deep Sedation • Deep sedation and analgesia is a drug induced depressed level of consciousness in which children respond purposefully only to repeated or painful stimulation.

9. General Anesthesia • General anesthesia refers to the drug induced loss of consciousness in which there is no response to painful stimulus.

10. Sedation for Cooperation • MRI • CT scan • Echo-cardiogram

11. Sedation for Painful Procedures • Lumbar puncture • Bone marrow aspiration / biopsy • Renal biopsy • Chest tube insertion • Central line insertion

12. Sedation for Emergency Procedures • Incision and drainage • Fracture reduction / splinting • Repair of lacerations

13. Goals of Sedation • Mood alteration in order to allay the patient’s fear and anxiety • Maintenance of consciousness and cooperation for those patients who must be awake enough to cooperate throughout the procedure • Elevate the pain threshold with minimal changes in vital signs, protective reflexes and physiologic response

14. Sedation and Analgesia Goals • Achieve adequate sedation with minimal risk • Minimize discomfort and pain • Minimize negative psychological response by providing anxiolysis, analgesia, and amnesia

15. Monitoring and AssessmentKey Elements • Pre-procedural criteria • Management during sedation • Post-procedure sedation assessment • Release from observation/dismissal/discharge criteria • Patient/child education and discharge instructions

16. Pre-procedural • ASA patient classification • Pre-procedural criteria • Feeding guidelines • Procedure / Site verification and time out

17. ASA Classifications • ASA Class • I: A normal healthy child • II: A child with mild systemic disease • III: A child with severe systemic disease • IV: A child with severe systemic disease that is a constant threat to life • V: A moribund child who is not expected to survive without the procedure

18. Pre-procedural Criteria • History and Physical • Informed consent • NPO status • Base-line vital signs • Height and weight • Adequate staffing • Emergency equipment

19. Health Assessment • Height / weight in kilograms • Vital signs including blood pressure • NPO status • Allergies • Current Medications • Systemic diseases or genetic conditions • Ability to intubated in the event of an emergency: size of jaw and ability to open mouth • History of heart murmur or asthma

20. Informed Consent • In an outpatient procedure a consent will need to be signed by a parent or legal guardian. • In and in-patient procedure consent my often be covered by the general hospital consent.

21. NPO Guidelines

22. NPO Guidelines • Breast fed infants should be fasted for the normal interval between feeding • When proper fasting has not been assured or in the case of a true emergency, “the increased risks of sedation must be weighted against its benefits; and the lightest effective sedation should be used. An emergency child may require protection of the airway (intubation) before sedation”

23. JCAHO Standards • Procedure /Site Verification • Marking the operative site • Time Out before procedure

24. BRN Scope of Practice • Nurse Practice Act • It is within the scope of practice of registered nurses to administer medications for the purpose of induction of conscious (procedural) sedation for short-term therapeutic, diagnostic or surgical procedures.

25. RN Responsibilities / Medications • The knowledge base includes but is not limited to: • Effects of medication • Potential side effects of the medication • Contraindications for the administration of the medication • Amount of medication to be administered

26. RN Responsibilities / Safety • Nursing assessment of the patient to determine that administration of the drug is in the patient’s best interest. • Safety measures are in force: • Back-up personnel skilled and trained in airway management, resuscitation, and emergency intubation. • Patient should never be left un-attended • Registered nursing functions may not be assigned to unlicensed assistive personnel.

27. RN Safety Concerns • Continuous monitoring of oxygen saturation • Cardiac rate and rhythm • Blood pressure • Respiratory rate • Level of consciousness • Immediate availability of an emergency cart which contains resuscitative and antagonist medications, airway and ventilatory equipment (defibrillator , suction equipment, means to administer 100% oxygen.

28. Institution Responsibilities • The institution should have in place a process for evaluating and documenting the RNs demonstration of the knowledge, skills, and abilities for the management of clients receiving agents to render conscious sedation. • Evaluation and documentation should occur on a periodic basis.

29. Management During Procedure • Patient monitoring • Reportable conditions • Side effects of sedation • Benefits of sedation • Medications

30. Monitoring During Moderate Sedation • Heart rate, blood pressure, breathing, oxygen level and alertness are monitored throughout and after the procedure

31. Reportable Conditions • Oxygen saturation less than 90% or 3% decrease from baseline • Change in vital signs of 20% or more • Respiratory depression or distress • Cardiac dysrhythmias • Deep sedation or loss of consciousness • Inadequate sedation and/or analgesic effect • Interventions and patient response • Failure to return to baseline status within one hour

32. Nursing Management • Personnel • Equipment • Medications • Medication reversal agents • Management parameters • Complications

33. Equipment/Supplies Needed for Sedation • Pulse oximeter • Cardiac monitor (if CV disease or arrhythmias detected or anticipated) • Blood pressure cuff • Crash cart in vicinity • Defibrillator • Suction • Emergency drugs and resuscitation equipment • Ambu bag & mask • Suction (device and Yaunker catheter) • O2 tubing & mask • Patent IV site • Reversal agents ** at bedside • Oral/nasal airway and ET tube of appropriate size

34. Medications used for Sedation and Analgesia

35. Midazolam (Versed) • Classification: Benzodiazepine • Potent sedative, anxiolytic and amnestic with no analgesic effects. • Action: short-acting CNS depressant. • Desired sedation can be achieved in 3 to 6 minutes • Indication and uses: to produce sedation, relieve anxiety, and impair memory of peri-operative events. • Suited for procedures that are not especially painful: central catheter placement, VCUG, CT scan

36. Versed Dosing • Midazolam can be given orally, intravenously, intra-nasally or rectally • Dosing: • Neonate dose: IV 0.05-0.2 mg/kg • Children dose: Oral: 0.2-.04 mg/kg (max dose 15 mg) IM: 0.08mg/kg IV: 0.003-0.05 mg/kg (max dose 2.5 mg)

37. Chloral hydrate • Classification: Sedative/Hypnotic, Non-barbiturate, no analgesic properties • Dosing • Neonate: Oral: 30-75 mg/kg/dose Maintenance dose: 20-40 mg/kg/dose • Children: Oral 25-100 mg/kg/dose (max dose of 1 gm for infants & 2 gm for children)

38. Morphine Sulfate • Classification: Narcotic analgesic • Action: opium-derivative, narcotic analgesic, which is a descending CNS depressant. Immediate pain relief lasts up to 4 to 5 hours.

39. Morphine Surlfate Morphine dosing • Neonate : IV 0.05 mg/kg **Neonates may require higher dose range- (0.1 mg/kg) • Children: Oral: 0.1-0.3mg/kg IV: 0.03-0.05 mg/kg (max dose 10 mg/dose) • Adolescents: Oral 5-8mg/dose IV: 3-4 mg/dose

40. Meperidine (Demerol) • Classification: Narcotic Analgesic • Action: Synthetic narcotic analgesic and CNS depressant, similar but slightly less potent than Morphine • Dosing • Neonate: IV 0.5 mg/kg/dose • Child: oral / SC / IM 1-2 mg/kg/dose (max 100 mg/dose) • Child IV: 0.5 – 1 mg/kg/dose (max 100 mg/dose)

41. Fentanyl • Classification: potent opioid analgesic • Useful for short painful procedures such as bone marrow aspiration, chest tube placement and fracture reduction. • Dosing for patients over 2 years of age • 1 to 3 mcg/kg/dose over 3 to 5 minutes • May be repeated in 30 to 60 minutes

42. Ketamine • Classification: general anesthetic producing both analgesia and sedation while maintaining airway tone. • Action: blocks association pathways, inducing a dreamlike state of mind before producing a sensory blockage. • Uses: especially useful for short, painful procedure.

43. Ketamine • Dosing • Neonate: 0.5mg-mg/kg • Children: Oral 6-10mg/kg in liquid—poor absorption when given orally IV: 0.5 mg-mg/kg IM: 3-7 mg/kg

44. Reversal Agents • Benzodizepine antagonist antidote • Naloxone Hydrochloride narcotic antagonist

45. Flumazenil (Romazicon) • Classification: Benzodiazepine antagonist • Action: reverse the effects of procedural sedation • Neonates: IV 2-10 mcg/kg every minute times 3 doses • Children: Initial dose: IV: 0.01 mg/kg, max initial dose 0.2 mg/dose • Repeat doses: 0.0005-0.01 mg/kg (max 0.2 mg repeated at 1 minute intervals • Max total dose: 1 mg or 0.05 mg/kg (which ever is lower)

46. Naloxone (Narcan) • Classification: Narcotic antagonist • Uses: narcotic overdose, post-operative narcotic depression • Dosing • Neonate: 0.1 mg/kg/dose • Children IM/IV/SC: 0.01 -0.1 mg/kg May repeat dose every 2-3 minutes (max dose is 2 mg/dose.

47. Allergic Reactions • Nursing alert: If procedure involves infusion of a contrast material – watch for allergic reaction • Hives, rash, flushing, uticaria, laryngeal edema, hypotension • Benadryl would be the drug of choice for an allergic reaction.

48. Post-Procedural Management

49. Post-Procedural Monitoring • Parameters and accompanying timeframes: • Monitor every 15 minutes post-procedure until: • child sips clear fluids • child returns to prior mobility status

50. Post-Procedural Monitoring • Parameters and accompanying timeframes: • Monitor continuously if: • child has history of cardiac or respiratory disease • Excessive sedation used • Vital sign instability • O2 desaturation during procedure • If reversal agent used • Recovery assessment must continue for 2 hours following the final dose - “Emergence phenomena”