Transcript Slides

THE USE OF ANALGESICS,
SEDATIVE MEDICATIONS PAIN,
SEDATION IN CHILDREN
Compiled by Tina M. Slusher, MD
University of Minnesota
Contributions from:
JOHN BERKENBOSH, M.D.
University of Louisville
CHERI LANDERS, M.D.
University of Kentucky
LYNNE W. COULE, M.D.
Medical College of Georgia
DAVID ROSEN, M.D.
West Virginia University
STEVE BARNES, M.D.
Rush University
Conflict of Interest
• I have nothing to disclose
Which of the following is true
regarding pain management?
• 1. Pain management affects wound
healing
• 2. PTSD is not related to acute pain
management
• 3. Neonates don’t feel pain
Importance of Effective Pain
Control
• Untreated pain has psychological
effects
• Exacerbates injury and may 
mortality
• Contributes to delayed wound healing
• Contributes to development of
chronic pain and PTSD
Bowman et al J of Trauma &Acute Care Surgery 2011
Non-pharmacological pain
control-audiovisual distraction
• Decreased pain
• Increased cooperation
• Decreased time of procedure
Swiss Med Wkly. 2008 Oct 4;138(39-40):579-84.
The efficacy of non-pharmacological methods of pain management
in school-age children receiving venepuncture in a paediatric department:
a randomized controlled trial of audiovisual distraction and routine psychological intervention.
Wang ZX, Sun LH, Chen AP.
J Prev Med Hyg. 2012 Mar;53(1):44-8.
Distraction techniques in children during venipuncture:
an Italian experience.
Bagnasco A, Pezzi E, Rosa F, Fornonil L, Sasso L.
Anesthesia Myths cont.
• Wrong!! Children do feel pain and
neonates likely feel even more pain
• Pain transmission begins @2weeks
gestation w/development of skin and
mouth sensory neurons
• Appearance of pain inhibitory
apparatus begins at about 32 wks
gestation
• <20 years ago common belief was than
infants did not feel pain and no anesthesia
was used even during surgery
• In 1992, a trial showed deep anesthesia
during cardiac surgery↓ physiologic stress
responses and mortality & gave convincing
evidence of importance of adequate
analgesia for newborn infants
• Untreated pain may have undesirable longterm consequences, even after fairly minor
procedures
Nelson’s textbook
Analgesia/Sedation Myths
Concerns about respiratory depression
make pain control impossible in
children
Wrong again!!!
– Need to titrate and Need to monitor
– Easy to overshoot in < 6 months
– Caveat in the < 6 month old infant
• Opioids can cause apnea prior to pain relief
• Neonates may not get good pain relief from
morphine but is commonly used in neonatesmore studies needed.
Analgesia/Sedation Myths
• True addiction rarely happens with
appropriate pain control
• “Addiction”
– Addiction vs. Tolerance vs. Dependance
Addiction
• A common fear voiced by health care
workers
• Includes a psychological “need” or
craving along with physical
withdrawal symptoms if medication is
discontinued
• People in real pain DON’T become
addicted as long as medication
titrated to pain
Tolerance
• The same dose of medication no longer has
the same effect as when first started
• More commonly occurs in patients on long
term continuous infusions of sedatives or
analgesics rather than intermittent dosing
especially if not titrated to the clinical
situation
• There are currently NO medications to
which tolerance will not develop
Dependence
• Removing medication results in
withdrawal symptoms
• To avoid withdrawal, may need to
wean sedative or analgesic or change
to long acting agents such as
methadone or clonidine when patient
has been on the medication for 1
week or more
ASSESSING PAIN
• JCAHO – pain as 5th vital sign
(mandate)
• Developmental and cultural barriers
– Ability to verbalize
– Cultural attitudes to pain
coping/treatment
• Non-painful contributors to “painlike” behaviors
Assessing Pain cont.
• Autonomic measures
– Heart rate
– Blood pressure
• Behavioral or combined behavioralphysiologic scales (e.g. facial expression,
limb movement ± heart rate & blood
pressure
What is Analgesia?
“Relief of the perception of pain
without intentional production of a
sedated state. Altered mental
status may be a secondary effect of
medications administered for this
purpose.”
WHO Golden Rules of Pain
Management
1. By the Clock
– Regular scheduling ensures steady blood
level
– PRN results in cycles of pain often
leading to increased pain med needs
2. With the child
– Regular pain assessment using
appropriate scales
• Scales available on line, standard
textbooks or hospital.
MANAGING PAIN
• 1990 – WHO pain management ladder
– Stepwise approach, based on anticipated
severity
– 1° developed for cancer pain, adapted
for all acute pain
• Outpatient and inpatient applications
• Enteral and intravenous routes encouraged
WHO LADDER
MILD PAIN:
– NSAIDS, Acetaminophen ± adjuvants
MODERATE PAIN:
– NSAID or acetaminophen ± weak opioid (oxy,
hydro, codeine) ± adjuvants
– IV opioids with scheduled NSAID or acetamin
• PCA vs CI vs intermittent
– Regional Anesthetic techniques
SEVERE PAIN:
– IV opioids (PCA/CI) ± adjuvants
– Regional Anesthetic techniques ± adjuvants
ANALGESIA
NSAIDS
• Ibuprofen:
–
–
–
–
–
Onset – 60-90 min
Peak – 2-4 hrs
Duration – 6-8 hrs
80% oral bioavailability
Hepatic metabolism via oxidation,
excreted in urine
8-10mg/kg/dose q 6-8hr PO or PR
NSAIDS cont.
• Naproxen ≥12yo to ≤65yo 200mg q68hr
• Diclofenac-start in adult 50mg tid
• All NSAIDS have similar analgesic
properties if used in equi-analgesic
dose and many of the same side
effects
ANALGESIA NSAIDS cont.
Ketorolac
– Only use IV if patient unable to take po
NSAID
– At equianalgesic dosing no more effective than
ibuprofen but has greater side effects
– 0.5-1 mg/kg q6h, po/IV/IM
– Onset – 10/30 min, peak – 40-60/90-180 min
– Duration – ~6 hrs
– Similar kinetics in infants, children, adolescents
– Time limited regimen
Codeine
• Poor analgesic properties
• Genetic variation means may lead to
toxic levels i.e ultra-rapid metabolism
can result in toxic accumulation of
morphine
• Don’t use if at all possible
Oxycodone
• Management of moderate-severe pain
• Comes as immediate and sustained
release
Morphine
• Opioid
• Advantages
– Analgesia
– Less expensive than fentanyl
• Disadvantages
– no amnesia, anxiolysis
– Histamine release - wheezing,
hypotension
– Urinary retention
– Longer onset than fentanyl
ANALGESIA
MORPHINE
• Dose/route
– IV/IM - 0.05-0.1mg/kg/dose - onset 2-3 min,
duration 3-4 hr
• infusion 0.01-0.04 mg/kg/hr
– po - 0.2-0.5 mg/kg - slow - onset 30-60 minutes
– onset – <5 min/1 hr
– Peak – 20 min/1-2 hr
– Duration – 3-5 hr
Rectal Morphine also option
0.2 mg/kg/dose
ANALGESIA
MORPHINE
• More widely available than fentanyl
• Advantages:
-Cheap
• Disadvantages:
– pruritus, hypotension, bronchospasm,
sedation, urinary retention
ANALGESIA
FENTANYL
• Synthetic opioid, ~ 100X more potent than
morphine
• More “hemodynamically friendly” than
morphine
– 100x more potent than morphine
– shorter duration than morphine
• onset in 2-3 min, lasts 30-60 min
– less histamine release than morphine
Fentanyl
• Disadvantages:
– no amnesia
– “Steel chest” or “rigid chest”
phenomenon
• more likely with large bolus dose
• Treat with reversal of fentanyl or
paralyzation or midazolam
Fentanyl cont.
• Dose/route:
– IV - sedation/analgesia - 1-3
mcg/kg/dose
- anaesthesia - 5-10 mcg/kg/dose
- infusion - 3-5 mcg/kg/hr
– Oral - 5-10 mcg/kg
– IN-1.5-2.0 mcg/kg
ANALGESIA
FENTANYL
• IV/transmucosal
–
–
–
–
onset – <2 min/5-15 min
Peak – <5 min/20 min
Duration – 30-60 min/1-2 hr
Transmucosal – 25% buccal (rapid), 75% GI
(slow)
Tramadol
• Non-opioid analgesia but works on opioid
receptors w/weak opioid
• Don’t mix w/strong opoid like morphine or pain
make worsen
• Central inhibition of seroton and non-epinephrine
• Causes some inhibition of ascending pain pathway
• PO
• Dose 1-2 mg/kg/dose q 4-6 hours (max
400mg/day)
Pethidine
• Bad choice but sometimes only one
available
• Agonist-Antagonist
• Metabolite can build up and cause
respiratory depression w/out
adequate pain control
• Often underdosed
• Dose 0.3-1mg/kg/dose q6hours
Ketamine
• Low dose ketamine may be
alternative for pain control
• See latter section on ketamine for
more information
Sucrose/Breastfeeding in
Neonates
• Sucrose with or without a pacifier can be
used for both pain and stress control in the
neonate
• Breastfeeding + sucrose or glucose may be
best alternative?
• However, recent article in Lancet questions
whether oral sucrose actually does reduce
pain because although pain score was lower
there was no difference in nociceptive or
spinal withdrawal activity (Slater R et al, Lancet.
2010;376:1225-1232
ANALGESIA
NALAXONE (NARCAN)
• Reverses sedation, analgesia, respiratory depression
• NO agonist activity so NO risk sedation/respiratory
depression with overdoses
• Use has decreased as a reversal agent because of risk
of re-sedation
• Dose: 0.1 mg/kg IV/IM
– use incremental doses (0.005-0.01 mg/kg) to avoid adverse
• Adverse:
– short half-life, resedation/depression
– opioid withdrawal (infants of addicted mothers)
– agitation, seizures, N+V
Naloxone in Low Doses
• Used to treat itching associated
w/narcotics as low-dose continuous
infusion
• Used to Rx nausea unresponsive to antiemetics
• Can be given po to treat constipation
from narcotics unresponsive to other
bowel regimes [(1mg/mL) 4 mL po BID to
TID in older children/adults; 1-2mL po BIDTID in younger children]
Tina M. Slusher, MD
Associate Professor of Pediatrics
SEDATION
RATIONALE
• Anxiety
– underlying illness
– separation from parents
– transport environment and transfers
• Ability to perform procedure
– Safety - risks of motion (invasive)
– Motion interference (i.e. radiologic)
PRESEDATION ASSESSMENT
HISTORY
• Brief and Targeted:
– Procedure being done and why
– Pertinent past history
• underlying medical conditions
• prior sedations/anaesthetics and reactions to them
• Underlying airway issues
– Present medications - consider possible
interactions
– Allergies - get specifics - not all reactions are
allergies-include food allergies as well
– Family history of anaesthetic reactions
– NPO Status
– Determine specific sources of anxiety
• Patient’s NPO status
– <6 mo 2 hours for clears and 4 hours for
breast milk and 6 hours for formula or
food
– >6 mo 2 hours for clears and 6 hours for
food unless diabetic or GER or other
situations at increased risk for delayed
emptying
PRESEDATION ASSESSMENT
PHYSICAL EXAM
• Vital signs including baseline SaO2
• General evaluation looking for evidence
– illnesses, toxicity
– volume depletion
– obesity
• Airway exam
– micrognathia/macroglossia, tonsils/adenoids
– ability to open mouth well
• Lung exam
– Wheezing, air exchange
• Cardiac exam
– Unrecognized heart disease
– Volume status
• Neurologic status
– Ability to protect airway
– Ability to cooperate with exam.
ASA Physical Status
Class I: Healthy patient
Class II: Systemic disease-well controlled
Class III:
Severe systemic disease
Class IV: Severe systemic disease that is
a constant threat to life
Class V: Moribund / not expected to
survive without surgery
AGENT DETERMINATION
•
•
•
•
Relative need for anxiolysis vs analgesia
Depth of sedation desired/required
Duration of procedure
Degree of patient/family anxiety
– prior experiences with procedures  sedation
• Underlying medical conditions
– include family history of reactions to
anaesthetics
– airway - obstruction, oral anatomy, CLDz
– hemodynamic - volume status, cardiac function
Sedation and Pain Control
are synonymous.
ls
e
50%
Fa
Tr
ue
1. True
2. False
50%

Some drugs like barbiturates actually
increase pain by
inhibiting neural pathways
SEDATION
DEFINTIONS
Mild (Conscious) Sedation
• minimally depressed level of consciousness
• ability to independently maintain airway patency retained
• respond appropriately to physical or verbal stimulation
Deep (Unconscious) Sedation
• controlled state of decreased or lost consciousness
• risk of partial/complete loss of airway protection/patency
• partial/complete inability to respond appropriately
General Anaesthesia
• medically controlled state of unconsciousness
• complete loss of airway protection and responsiveness
Continuum of
Consciousness
Awake,
baseline
Conscious
sedation
Drowsy
General
anesthesia
Deep
sedation
ALL SEDATION CAN PROGRESS TO
DEEP SEDATION REGARDLESS OF
THE DRUG OR DOSE EMPLOYED!
Equipment
• Check your equipment & make sure it’s the
right size for your patient and in working
condition
• Must have equipment for
–
–
–
–
Securing airway
Assisting ventilation
Supporting circulation
Suctioning equipment/supplies
• PPV (ambu) bag, appropriate mask, IV supplies,
& suctioning equipment are the basic minimum
What is the Best
Monitoring Tool
•
•
•
•
1. Pulse oximeter
2. Blood pressure
3. Cardiac monitor
4. Eyeballs
MONITORING
• Absolute MINIMUM:
–
–
–
–
(after Two eyeballs looking at the patient)
Continuous HR, SaO2
Intermittent (q5-15 min) BP
DOCUMENTATION – frequent HR, RR, BP, SaO2
• Consider:
– EKG
– ET-CO2
• Hypercarbia and hypoxemia not always
simultaneous and if available ET-CO2 probably
better than sat
•
as it picks up changes quicker
CONCEPTS
Analgesia
Sedation
Anxiolysis
Paralysis
DRUG CLASSES
• Sedatives
benzodiazepines
barbiturates
chloral hydrate
2 receptor agonists
• Analgesics
opioids
ketamine
• Anaesthetics
ketamine
propofol
Benzodiazepines
• Amnesia
– Antegrade and retrograde
• Anxiolysis
• Respiratory Depression
• Skeletal muscle relaxation
Midazolam (Versed)
• Advantages:
–
–
–
–
anxiolysis, sedation, some motion control
retrograde amnesia
PO, IV, IM, IN*, PR dosing routes
onset 2-6 min after IV administration,
45-60 min duration
– available reversal agent
• Flumazenil
*For IN ideally need
Concentrated 5mg/mL
Midazolam (Versed)
• Disadvantages
– No analgesia
– Paradoxical reactions
– More than additive risk of respiratory
compromise when added to opiate
– Neonates: bradycardia, hypotension and
seizures with rapid injection
– Peak serum level increased with
itraconazole, erythromycin and
clarithromycin
Diazepam
• Advantages: Similar to other benzo’s
except longer acting, metabolites can
accumulate over time causing toxicity
especially w/larger doses
• Dosage for sedation:
– 0.04-0.2mg/kg/dose IV/IM q2-4 hours
(maximum 8 mg in 24 hours)
– 0.12-0.8 mg/kg/24 hours PO divided q6hours
Barbiturates
•
•
•
•
•
General CNS depressants
Induction of anesthesia
Hypnosis
Sedation
Respiratory depression
Pentobarbital (Nembutal)
• Advantages:
– Fairly safe
– Sedation, motion control, anxiolysis
– Short onset (3-5 min. given IV) and
duration (15-45 min.)
– Alternative to chloral hydrate in older
children
– PO, IV, IM, PR dosing routes
• longer time to onset and longer duration with
routes other than IV
Increases pain perception
Thiopental
• Primarily used for induction of
anesthesia, seizure control and
increased ICP
• Provides no pain control
Propofol
• Sedative/hypnotic anesthetic
• Increased popularity for procedural
sedation
– Rapid onset and recovery
– Lack of agitation
– Anti-emetic properties
• Deep sedation for short procedures
– Consider concomitant analgesic or local
anaesthetic
NO significant Analgesic Properties
PROPOFOL
• Administration:
– 1-2 mg/kg/dose – slowly and titrate
– Infusion (3-5 mg/kg/hr) or frequent small
boluses
• Onset/Duration:
– Rapid onset (1-2 minutes)
– Rapid recovery - baseline in 10-15 minutes
• Adverse:
– Respiratory depression/airway protection
• Dose-dependent
• Smaller therapeutic window than ketamine
– Hypotension/bradycardia
– Pain at injection site – lidocaine helps~I mix
1mg/kg in first 10cc syringe of propofol ~less
problematic w/larger IV’s
Propofol cont.
• Adverse:
– Respiratory depression/airway
protection
• Dose-dependent
• Smaller therapeutic window than ketamine
– Hypotension/bradycardia
– Pain at injection site - lidocaine
DEXMEDETOMIDINE
• Sedation, anxiolysis
• Analgesia – some but not great
• Hypertension
• Bradycardia/hypotension
• Diuresis
• Minimal respiratory depression
Narcotics Plus Benzo’s
• Monitor closely for respiratory
depression esp. when used in combination
w/benzodiazepines!
• Remember that narcotics plus benzo’s
=
more respiratory depression than either
alone!
Ketamine
• Dissociative anesthetic
• Advantages
– provides both analgesia and amnesia
– less alteration of upper airway tone and
reflexes than benzo’s or narcotics
– preserves upper airway tone and reflexes
– causes bronchodilatation
• Although studies don’t all agree ketamine
likely reduces the dose of morphine when
used together. (Carstensen & Moller, BMJ, 2010, 401-6)
Ketamine
• Disadvantages
– increases intracranial pressure
– laryngospasm
– hypersecretory response (can lessen
with use of
glycopyrrolate-best or atropine)
– emergence phenomenon/agitation (can
lessen with benzo’s)
Ketamine
• Relative contraindications
– head injury
– airway abnormalities
– procedures where posterior pharynx will
be stimulated
– glaucoma, acute globe injury
– psychosis
– thyroid disorder
– uncontrolled hypertension
KETAMINE
• Dose:
– IV - 1-2 mg/kg initially repeat 0.5-1 mg/kg as
needed
– IM - 3-6 mg/kg
– PO – 5-10 mg/kg
– IN-9mg/kg
– Suggest adding antisialagogue, benzodiazepine
Tsze IN Ketamine for procedural sedation
In pediatric laceration repair : a preliminary report
Pediatr Emerg Care 2012
Ketamine cont
• Onset/Duration:
– rapid onset (<1 min IV, 5-10 minutes IM,
10-15 PO)
– dissociation lasts 15-30 minutes, return
to baseline usually by 30-60 minutes
after last dose