Transcript Pain Management and Sedation

Pain Management and Sedation
Nightfloat Curriculum 2010-2011
LPCH Pediatric Residency Program
Teaching Goals
• Be comfortable initiating pain medications
• Learn to assess pain and modify treatment
strategies
• Know how to choose appropriate sedation
strategies based on patient age and procedure
Pain Management
• Pediatricians often under-treat children’s pain
• When initiating pain medications, a standing
regimen is preferable
– PRN = Patient Not Receiving
– Avoid combination products (i.e. Vicodin) at first
• Constantly re-assess your pain plan
– Is it working?
– Any side effects?
Assessing Pain
• Infants
– FLACC
• Verbal Children
– Scale of 1-10 (may use faces and/or numbers)
FLACC
0
1
2
FACE
No particular
expression or smile
Occasional grimace
or frown,
withdrawn,
disinterested
Frequent to
constant quivering
chin, clenched jaw
LEGS
Normal position or
relaxed
Uneasy, restless,
tense
Kicking or legs
drawn up
ACTIVITY
Lying quietly,
normal position,
moves easily
Squirming, shifting
back and forth,
tense
Arched, rigid, or
jerking
CRY
No cry
Moans or
whimpers,
occasional
complaint
Crying steadily,
screams or sobs
CONSOLABILITY
Content, relaxed
Reassured by
touching, hugging,
voice, distraction
Difficult to console
of comfort
Pain Medications
• Acetaminophen
– PO: 10-15 mg/kg every 4-6 hours
– PR: Loading dose 35-50 mg/kg; Maintenance dose 20
mg/kg every 6 hours
– NO MORE THAN 5 DOSES in 24 hours
• Ibuprofen
– PO: 5-10 mg/kg every 6-8 hours
– MAX 40 mg/kg/day
– Contraindicated in active GI bleeding, hypersensitivity
to NSAIDs
– Caution in severe asthmatics
Pain Medications
• OPIATE – If one doesn’t work, try another
• AVOID Codeine
– 1/3 of patients gain no analgesia
• Morphine
– PO: 0.2-0.5 mg/kg every 4-6 hours
– IV: 0.05-0.2 mg/kg every 2-4 hours
– PCA: 0.015 mg/kg/hr basal with 0.015 mg/kg PCA
dose q10 min lockout
Pain Medications
• Oxycodone
– PO: 0.1-0.2 mg/kg every 3-4 hours
• Fentanyl
– IV: 0.5-4 mcg/kg every 1-2 hours
• Hydromorphone
– PO: 0.03-0.08 mg/kg every 3-4 hours
– IV: 0.015 mg/kg every 3-6 hours
Moderate Sedation
• Patient Assessment
– ASA Class
– Airway
– Allergies
• Informed Consent
– Risks and benefits
Moderate Sedation
•
•
•
•
Sedation certified nurse
Monitoring
Suction and bag-mask readily available
Reversal agents ordered and drawn up
Moderate Sedation
• Midazolam
– PO: 0.5 mg/kg per dose, may repeat with 0.25
mg/kg; max 20 mg
– IV: 0.05-0.1 mg/kg per dose, may repeat up to
total of 0.2 mg/kg
– Intranasal: 0.2-0.3 mg/kg per dose administered in
1 ml syringe over 15 seconds
• Lorazepam
– IV, PO: 0.05 mg/kg/dose every 4-8 hours; max 2
mg per dose
Moderate Sedation
• Chloral Hydrate
– PO: 50 mg/kg as single dose, may repeat with 25
mg/kg after 20 minutes; max 100 mg/kg in 24
hours
– Preferred in younger children and with painless
procedures
• Pentobarbital
– PO, IM, IV: 4 mg/kg, may repeat with 2 mg/kg;
max is 100 mg
– May cause HYPERalgesia – avoid in painful
procedures
Reversal Agents
• Flumenazil
– IV: 0.01 mg/kg/dose given over 15 seconds, may
repeat every minute; max TOTAL dose is 0.05
mg/kg or 1 mg
• Naloxone
– IV, IM, ET, SubQ: 0.001 mg/kg/dose, MINIMUM
dose is 0.01 mg, may repeat every 1-2 minutes
Case 1
• 15 month infant needs an urgent lumbar
puncture. What agents would you use for
sedation and analgesia?
• What if she needed to get an MRI?
Case 2
• A 4 year old has recently returned from having
an abcess drained and has a painful JP drain in
place. How would you treat his pain?