Transcript SediationAnalgesiaNursingMgt

Pediatric Sedation and Analgesia
Jan Bazner-Chandler
RN,MSN, CNS, CPNP
PSA
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Procedural sedation and analgesia (PSA) refers to the
pharmacologic techniques of minimizing or eliminating a
child’s pain and anxiety related to invasive or potentially
frightening treatments & procedures.
Historical Perspective
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AAP (American Academy of Pediatrics) seminal article
1992 referred to as “conscious sedation”, & established
guidelines for monitoring these patients.
Defined as “a depressed state of consciousness where the
patient retains protective reflexes and responds
appropriately to stimuli”.
AHCPR (Agency for Health Care Policy & Research)
published federal guidelines for management of acute pain
in adults & children.
Procedural Sedation Re-defined
American College of Emergency Physicians re-named
“conscious sedation” as “moderate sedation”
because
Procedural sedation’s goal was to medicate patients safely
until they can tolerate unpleasant procedures; i.e, they
aren’t really “conscious”.
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AHCPR Guidelines
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Provide adequate
preparation of children
& families for procedure
Be attentive to
environmental comfort
(allow parents to stay,
quiet room, sign on
door)
3.Combine
pharmacological & nonpharmacological options
when possible (relaxation
& imagery/VR)
4. If procedures will be
repeated, provide max
S&A for 1st procedure
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Four Levels of Sedation
The Joint commission and the American Society of
Anesthesiologists (ASA) described the 4 levels of
sedation.
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Anxiolysis
Moderate Sedation
Deep Sedation
General Anesthesia
Minimal Sedation
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Anxiolysis or minimal sedation refers to a drug-induced
state in which cognitive and motor function may be
impaired. This state does not fall under the sedation
monitoring strict guidelines.
Moderate Sedation
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Moderate sedation is a state of sedation in which a child
responds purposefully to verbal commands with or
without light tactile stimulation, and maintains protective
reflexes.
Deep Sedation
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Deep sedation and analgesia is a drug induced depressed
level of consciousness in which patients respond
purposefully only to repeated or painful stimulation, and
may be accompanied by the loss of protective reflexes.
General Anesthesia
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General anesthesia refers to the drug induced loss of
consciousness in which there is no response to painful
stimulus, and loss of protective reflexes.
requires the patient to be very still for the
duration of the procedure, which may be
frightening for the child)
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MRI
CT scan
Echo-cardiogram (rarely)
Radiation therapy
Sedation/Analgesia for Painful Procedures
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Lumbar puncture
Bone marrow aspiration / biopsy
Renal biopsy
Chest tube insertion/removal
Central line insertion/removal
Peritoneal tap
Sedation for Emergency Procedures
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Incision and drainage
Fracture reduction / splinting
Repair of lacerations
Goals of Sedation
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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
Complete the procedure safely in minimum time
Sedation and Analgesia Goals
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Achieve adequate sedation with minimal risk, minimal
time
Minimize discomfort and pain
Minimize negative psychological response by providing
anxiolysis, analgesia, and amnesia
Monitoring and Assessment
Key Elements
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Pre-procedural criteria
Management during sedation (intra-procedural)
Post-procedure sedation assessment
Release from observation/dismissal/discharge criteria
Patient/child education and discharge instructions
Pre-procedural
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ASA patient classification/Modified Aldretti Score
Pre-procedural criteria
Feeding guidelines
Procedure / Site verification and time out (Universal
Protocol)
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
Pre-procedural Criteria
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History and Physical/allergies/sedation hx
Informed consent..for procedure and sedation/analgesia
drugs
NPO status
Base-line vital signs
Height and weight
Adequate staffing
Emergency equipment
Health Assessment
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Height / weight in kilograms
Vital signs including blood pressure
NPO status
Allergies
Current Medications (which may affect sedation level)
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
Informed Consent
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a consent will need to be signed by a parent or legal
guardian for the procedure & medications, & should be
accompanied by a note in the medical record.
What constitutes an ‘informed consent?”
NPO Guidelines
Age
Duration of fasting
(milk, formula, solids)
Duration of fasting
(clear liquids)
Infants
who
receive
formula or
breast milk
Children>3
years
6 hours for formula fed
infants
4 hours for breast fed
infants
2 hours
8 hours
2 hours
NPO Guidelines
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Breast fed infants should be fasted for the normal interval
between feeding
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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. In an emergency situation the child may
require protection of the airway (intubation) before sedation”,
and emptying the stomach as much as possible.
TJC (The Joint Commission) Standards
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Procedure /Site Verification
Marking the operative site
Time out before procedure (Universal Protocol)
All must be documented in the MR
BRN Scope of Practice
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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.
RN Responsibilities / Medications
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The knowledge base includes but is not limited to:
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Effects of medication/appropriateness of order
Onset, peak, duration/reversal meds
Potential side effects of the medication
Contraindications for the administration of the medication
Amount of medication to be administered/safe & therapeutic
dose
RN Responsibilities / Safety
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Nursing assessment of the patient to determine that
administration of the drug is in the patient’s best interest.
Safety measures are in force:
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Back-up personnel skilled and trained in airway management,
resuscitation, and emergency intubation. One must be PALS
certifies)
Patient should never be left un-attended
Registered nursing functions may not be assigned to
unlicensed assistive personnel.
RN must have no other duties other than to administer meds
& monitor the patient
RN Safety Concerns
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Continuous monitoring of oxygen saturation
Cardiac rate and rhythm
Blood pressure
Respiratory rate
Level of consciousness/response to interventions
Immediate availability of an emergency cart which
contains resuscitative and antagonist medications, airway
and PP ventilatory equipment (bag & appropriate size
mask, defibrillator, suction equipment, means to
administer 100% oxygen).
Institution Responsibilities
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The institution should have in place a process for
evaluating and documenting the RN’s training &
competency for the management of clients receiving
procedural sedation.
Evaluation and documentation should occur on a periodic
basis.
Management During Procedure
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Patient monitoring
Reportable conditions
Side effects of sedation
Benefits of sedation
Medications
Monitoring During Moderate
Sedation
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Heart rate, blood pressure, breathing, oxygen level and
alertness are monitored throughout and after the procedure
Reportable Conditions
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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 2 points of PreAldretti score within one hour)
Nursing Management
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Personnel
Equipment
Medications
Medication reversal agents
Management parameters
Complications
Equipment/Supplies Needed for Sedation
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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
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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
Medications used for Sedation and
Analgesia
Midazolam (Versed)
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Classification: Benzodiazepine
Potent sedative, anxiolytic and amnestic with no analgesic
effects. Potent respiratory depressant.
Action: fast acting, 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-procedural events.
Suited for procedures that are not especially painful: central
catheter placement (with analgesia), voiding cystourethrogram (VCUG), CT scan, MRI
Versed Dosing
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Midazolam can be given orally, intravenously, intra-nasally
or rectally
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Dosing:
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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)
Chloral hydrate
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Classification: Sedative/Hypnotic, Non-barbiturate, no
analgesic properties
Action:
Dosing
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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)
Onset: 30 minutes to one hour
Duration: 4 to 8 hours
Morphine Sulfate
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Classification: Narcotic analgesic
Action: opium-derivative, narcotic analgesic, which is a
descending CNS depressant. Immediate pain relief with IV
administration, peak analgesia at about 20 minutes, lasts
up 2 to 4 hours.
Morphine Surlfate
Morphine dosing
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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
Meperidine (Demerol)not used much in peds
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Classification: Narcotic Analgesic
Action: Synthetic narcotic analgesic and CNS depressant,
similar but slightly less potent than Morphine
Dosing
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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)
Fentanyl
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Classification: potent opioid analgesic/respiratory
depressant; fast and short-acting
Useful for short painful procedures such as bone marrow
aspiration, chest tube placement and fracture reduction.
Dosing for patients over 2 years of age
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1 to 3 mcg/kg/dose over 3 to 5 minutes
May be repeated in 30 to 60 minutes
Ketamine/only used under
anesthesiologist’s supervision
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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.
Ketamine
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Dosing
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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
Reversal Agents
Benzodizepine antagonist antidote: (Romazicon/flumazinil)
 Naloxone Hydrochloride narcotic antagonist (Narcan)
(Figure out doses before hand, don’t draw up but be ready)
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Flumazenil (Romazicon)
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Classification: Benzodiazepine antagonist
Action: reverse the effects of procedural sedation and
reverses paradoxical reaction
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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)
Naloxone (Narcan)
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Classification: Narcotic antagonist
Uses: narcotic overdose, post-operative narcotic
depression
Dosing
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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.
Allergic Reactions
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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.
Paradoxical reaction to versed
Post-Procedural Management
Post-Procedural Monitoring
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Parameters and accompanying timeframes:
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Monitor every 15 minutes post-procedure until:
child sips clear fluids
 child returns to prior mobility status
 Child returns to within 2 points of pre-procedural
Aldretti score
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Post-Procedural Monitoring
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Parameters and accompanying timeframes:
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Monitor continuously if:
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child has history of cardiac or respiratory disease
Excessive sedation used
Vital sign instability
O2 desaturation during procedure
If reversal agent used
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Recovery assessment must continue for 2 hours following the
final dose; reversal agents may not outlast sed/opioid drug effects.
- “Emergence phenomena”
Monitoring Discharge Criteria
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The following discharge criteria should be included, but not
limited to:
-adequate respiratory function
-stability of vital signs
-preoperative level of consciousness
-intact protective reflexes
-return of motor/sensory control
-absence of protracted nausea
-adequate state of hydration
Outpatient Considerations
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All outpatients must receive post-sedation
precautions and be discharged from the area
Written instructions must include:
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Post procedural complications
Activity limitations
Bathing instructions
Plan for follow-up care:
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Emergency numbers
Next physician appointment date