Transcript Sedation and Analgesia for ED101

Sedation and Analgesia
for ED101
Kalpesh N. Patel, MD
Dept. of Pediatric Emergency
Medicine
August 1, 2007
Objectives
 To review sedation/analgesia drugs, doses, and
nursing pain protocols
 To review pre-sedation workup and checklist
 To familiarize you with CHOA sedation policies and
practices
 To review sedation drugs and dosages
 Child Life Services
2
Analgesia
 “Pain is an unpleasant sensory and emotional experience
associated with actual or potential tissue damage or described
in terms of such damage.”
– American Pain Society 1992; Mersky, Bogduk, 1994
 Patient’s self-report is the single most reliable indicator of
pain.
 Unrelieved pain has negative physical and psychological
consequences.
 There is no diagnostic or therapeutic benefit to being in pain.
 Baseline pain rating is obtained at triage.
 Studies show that children do not get the same treatment as
adults who have similar painful conditions.
3
Assessing Pain
 For sedated, unresponsive patients use the
Objective Pain Scale (OPS)
4
Assessing Pain
 For non-verbal patients use FLACC behavioral
scale
5
Assessing Pain
 For pre-school and young school age children use
the FACES scale by patient self report
6
Assessing Pain
 For older school/adolescent patients use the 0-10
Numeric Pain Rating Scale by patient self report
7
Treatment Options
 Non-Pharmacologic Treatment:
• In most situations, parents are the best source of
comfort
• Promote a sense of control to the patient in a
developmentally appropriate manner
• Use treatment rooms away from other patients
and create a calm environment.
• Distraction
 Child Life
• Directed Imagery
8
Treatment Options
 Pharmacologic Treatment
• Mild pain (1-4/10): Acetaminophen and/or Ibuprofen
• Moderate pain (5-7/10): Ibuprofen and/or Tylenol with
codeine
• Severe pain (8-10/10): Ibuprofen and/or Lortab
 Acetaminophen 15mg/kg max of 1000mg
 Ibuprofen 10mg/kg max of 800mg
 Tylenol with Codeine 1mg/kg max of 60mg
 Lortab 0.15mg/kg
• 12-15 kg: 3.75cc
• 16-22 kg: 5cc
• 23-31 kg: 7.5cc
• 32 + kg: 10cc of elixir or 1 tablet of Lortab 5/500
9
Contraindications
 Do not give meds if allergic or hypersensitive
 Acetaminophen
• Known liver dysfunction
• Prior dose < 4 hrs
 Ibuprofen
• < 6 months of age
• Known renal dysfunction
• Prior dose <6 hrs
• Currently bleeding or known bleeding disorder
 Lortab and Tylenol with Codeine
• Same as acetaminophen contraindications
• Caution in constipation/abdominal pain
10
Treatment Options
 Local Analgesia
• Cold
 Ice
 Ethyl Chloride
 PainEase Refrigerant Spray
• Viscous lidocaine
• EMLA
• LMX
• LET
 SweetEase (24% sucrose solution)
• Start giving 2 min prior to
procedure
11
Sedation
 Levels of Sedation:
• Minimal Sedation (Anxiolysis)
• Moderate Sedation (Conscious)
• Deep Sedation
• General Anesthesia
 Sedation to anesthesia is a continuum and
movement into other levels is easy
12
Minimal Sedation
 Patient responds to verbal commands
 Ventilatory and cardiovascular functions are
unaffected
 A SINGLE drug given by RN, MD, or dentist
 Nitrous Oxide/O2 titrated up to a maximum of 50%
in conjunction with local nerve blocks or topical
anesthetics.
 Criteria:
• No history of apnea/bradycardia
 Vital Signs Q15min of HR, RR and SpO2 for 1 hour,
then hourly.
13
Moderate Sedation
 Patients respond purposefully to verbal commands
or LIGHT tactile stimulation
 Maintains protective reflexes including cough and
gag. No respiratory support needed
 Provided in designated safe areas:
• OR, PACU, ICU, ED, Radiology
 Vital Signs with continuous pulse ox every 5 min
14
Deep Sedation
 Patients cannot be easily aroused, but respond
purposefully to PAINFUL stimuli.
 Ventilatory function may be impaired.
• May need airway support and spontaneous
ventilation may be inadequate.
 Cardiovascular function is usually maintained.
 VS monitored every 5 min: HR, RR, BP, SpO2,
± ETCO2
15
General Anesthesia
 Includes general anesthesia and spinal or major
regional anesthesia.
 Patients are not arousable to ANY stimuli.
 Ventilatory function is often impaired and require
assistance.
16
Pre-Sedation Workup
 History
• Allergies
 Prior sedation reactions?
• Medications
• Past Medical History
 Pregnant? Drug Abuse? Apnea,
Seizure, Reflux, Snoring?
• Last Meal
• Events leading up to need for
sedation
 Physical
• Baseline Vitals and LOC
• Airway Exam
• Heart & Lungs
17
ASA Classification
Class
Physical status
I
Healthy patient
II
Mild systemic disease, no functional limitation
III
Severe systemic disease that limits activity
IV
Incapacitating systemic disease that is a constant treat
to life
V
Moribund not expected to survive 24 hrs without an
operation
 Add E if emergent/urgent
 ASA I and II are usually appropriate candidates
 ASA III cases should be individually considered
 ASA IV and V, consult anesthesia or ICU
18
NPO Guidelines
Breast Milk
Clear Liquids
Milk and NonClear Liquids
Solids
4 hours
2 hours
6 hours
6 hours
 A longer fast (8 hours) for fatty meals should be
considered
 Weigh risks/benefits for emergent situations
 As a general rule, we follow >4 hours to be safe for
sedation.
19
Equipment required
 Suction – ALWAYS CHECK BEFORE SEDATION
 Oxygen delivery system
 Airway equipment of appropriate size
 Emergency Medications (Code Drugs)
• Reversal Medications
 IV equipment
 Monitors
• Pulse Oximetry
• Cardiac/Blood Pressure
 NG Tube of appropriate size
20
Medications
 Chloral Hydrate
 Benzodiazepines
• Midazolam
• Diazepam
 Barbiturates
• Pentobarbital
• Thiopental
• Methohexital
 Opiates
• Morphine
• Fentanyl
 Ketamine
 Propofol
 Etomidate
21
Chloral Hydrate
 Unknown mechanism of
action
 Contraindicated in
hepatic or renal disease
 May have paradoxical
excitement
 Side Effects:
• Hypotension
• Cardiopulmonary
depression
• GI upset
 Simethicone
22
 Dose: 25-100 mg/kg PO/PR
• Max 1 gram in infants
2 grams in children
 Onset: 30-60min
 Duration 4-8 hours
Benzodiazepines - Midazolam
 The most commonly used
sedation agent in children
and adults
 Provides potent sedation,
anxiolysis, and amnesia
 Shorter acting than other
benzodiazepines
 May be given IV, PO, IN,
IM, or PR
 Bitter aftertaste so mix in
Syrpalta
 Burns in nose
23
 PO
• Dose: 0.5-1 mg/kg, max
20mg
• Onset: 15 min
• Duration: 30-90 min
 Intranasal or Sublingual
• Dose: 0.2-0.5 mg/kg,
max 10 mg
• Onset: 10-15 minutes
• Duration: 60 minutes
 IV
• Dose: 0.05-0.1mg/kg,
max 0.6mg/kg or 10mg
• Onset: 2-3 min
• Duration: 60-90 min
Benzodiazepines
 Has NO analgesic effect!
 Contraindicated with narrow angle glaucoma and shock
 May be reversed with flumazenil (0.01mg/kg IV)
 If a reversal agent is required the patient must be
observed for an additional 2 hours from the time the
reversal agent is given
24
Barbiturates - Pentobarbital
 Drug of choice for head
trauma, Status Epilepticus
 Side effects:
•
•
•
•
Myocardial depression
Hypotension
Respiratory depression
Bronchospasm- stimulate
histamine release
 Contraindications:
• liver failure
• CHF
• hypotension
 NO Analgesia!
25
 Dose:
• 2-6 mg/kg/dose PO/PR/IM
• 1-3 mg/kg/dose IV
• Max dose is 150mg
 Onset: 15-60 min
 Duration: 1-4 hours
Propofol
26
 Ultra short acting sedative
 Dose dependent level of
sedation with rapid
recovery time
 Profound respiratory
depressant and causes
apnea
 May depress cardiac
output and cause severe
hypotension
 Attending needs to be
present during the entire
infusion!
 Dose:
• 1-3 mg/kg IV
• Repeat 0.5mg/kg Q2-3
min
 Contraindicated in patients
with egg or soybean allergy.
 IV site pain – use 1%
lidocaine
Narcotics
 Gold standard for pain management
 Reversed with Naloxone
 Combination with benzodiazepines can cause
respiratory depression and dosage should be
reduced
27
Fentanyl - IV
 Preferred opioid
because of rapid onset,
elimination, and lack of
histamine release
 Rapid IV administration
can cause chest wall
rigidity and apnea
 Respiratory depression
may last longer than
the period of analgesia
28
 Dose is 1-2mcg/kg over 3-5
minutes
 Titrate to effect every 3-5
minutes
 Onset: 1-2 minutes
 Peak effect: 10 minutes
 Duration: 30-60 minutes
Morphine Sulfate
 Better for procedures
that have a longer
duration ( ≥ 30 minutes)
 Histamine release can
cause flushing and
itching
29
 Dose: 0.1-0.2 mg/kg
IV/IM/SQ, max 15 mg
 Onset: 5-10 minutes
 Duration: 2-4 hours
Ketamine
 Provides both analgesia and
sedation
 Releases endogenous
catecholamines
• Preserves respiratory
drive and airway
protective reflexes
• Bronchodilator effect
• Maintains hemodynamic
stability
 Rapid infusion causes
respiratory depression and
apnea
30
 Dose: 1 to 2 mg/kg IV
3 to 5mg/kg IM
 Onset: 1 minute IV
 Duration:
• 60 min for sedation
• 40 to 45 min for
analgesia
Ketamine - Complications
 Laryngospasm
 Apnea
 Hypersalivation
 Vomiting
 Agitation/Hallucinations/Emergence Reactions
 Hypertension
 Increased Intracranial and Intraocular Pressure
 Myoclonus
31
Ketamine - Contraindications
32
 Age of 3 months or younger
 Active pulmonary disease or infection
 Procedures resulting in large amounts of oral
secretions or blood
 History of airway instability, tracheal surgery, or
tracheal stenosis
 Intracranial hypertension (head injuries,
hydrocephalus, mass)
 Cardiovascular disease
 Glaucoma or acute globe injury
 Psychiatric illness
 Full meal within 3 hours
Etomidate
 Ultra short acting hypnotic
 Unknown mechanism of
action
 Rapid IV induction
 Minimal respiratory
depression or hemodynamic
instability
 Possible cerebral protection
 Contraindications:
• Seizure disorder
• Children < 2 y/o
33
 Dose: 0.2-0.5 mg/kg IV
 Induction 0.3 mg/kg IV over
30-60 sec
 Duration 5-10 min
 Full recovery in 30 min
 Re-dose with 0.1mg/kg
every 5-10 minutes as
needed
Etomidate
 Does not provide analgesia
 Adverse reactions
• Nausea and vomiting – 5%
• Causes burning infusion pain, decreased with
lidocaine
• Myoclonic movements, may stimulate seizure
activity
• Inhibits steroid synthesis
34
Consent
 Sedation consent must
be obtained
SEPARATE from
procedure consent
 Use for sedation
beyond SINGLE drug
Anxiolysis
35
Post-Procedure
 Reassessed and monitored by RN or PALS
Certified LPN.
 VS every 10 minutes until discharge criteria met
 For prolonged complications, admission to the
appropriate area is recommended, i.e., floor or ICU
 Family given written discharge instructions and
verbalize understanding
36
Discharge
 Vitals are appropriate for age
 Child has appropriate activity
for age
 Appropriately responds to
verbal stimuli
 Oxygen saturation returns to
normal baseline
 Maintains airway appropriately
 Modified Aldrete score of > 13
37
Special Considerations
 Infants < 52 weeks gestation + chronologic age
MUST be admitted for monitored observation for 12
hours minimum without apnea.
 Residents and fellows must have sedation reviewed
and approved by attending before administration
 Beware of patients in Radiology
38
Questions?
39