Pediatric Sedation and Analgesia

Jan Bazner-ChandlerRN,MSN, CNS, CPNP

PSA 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 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”

becauseProcedural sedation’s goal was to medicate

patients safely until they can tolerate unpleasant procedures; i.e, they aren’t really “conscious”.

AHCPR Guidelines1. Provide adequate

preparation of children & families for procedure

2. Be attentive to environmental comfort (allow parents to stay, quiet room, sign on door)

3.Combine pharmacological & non-pharmacological options when possible (relaxation & imagery/VR)

4. If procedures will be repeated, provide max S&A for 1st procedure

Four Levels of SedationThe Joint commission and the American Society

of Anesthesiologists (ASA) described the 4 levels of sedation. Anxiolysis Moderate Sedation Deep Sedation General Anesthesia

Minimal Sedation 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 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 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 General anesthesia refers to the drug induced

loss of consciousness in which there is no response to painful stimulus, and loss of protective reflexes.

Sedation for Cooperation(non-painful but requires the patient to be very still for the duration of the procedure, which may be frightening for the child) MRI CT scan Echo-cardiogram (rarely) Radiation therapy

Sedation/Analgesia for Painful Procedures Lumbar puncture Bone marrow aspiration / biopsy Renal biopsy Chest tube insertion/removal Central line insertion/removal Peritoneal tap

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

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

Complete the procedure safely in minimum time

Sedation and Analgesia Goals

Achieve adequate sedation with minimal risk, minimal time

Minimize discomfort and pain Minimize negative psychological response

by providing anxiolysis, analgesia, and amnesia

Monitoring and AssessmentKey Elements

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 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 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 AssessmentHeight / weight in kilogramsVital signs including blood pressureNPO status AllergiesCurrent Medications (which may affect

sedation level)Systemic diseases or genetic conditionsAbility to intubated in the event of an

emergency: size of jaw and ability to open mouth

History of heart murmur or asthma

Informed Consent 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

6 hours for formula fed infants

4 hours for breast fed infants

2 hours

Children>3 years

8 hours 2 hours

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. 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 Procedure /Site Verification Marking the operative site Time out before procedure (Universal Protocol) All must be documented in the MR

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.

RN Responsibilities / Medications The knowledge base includes but is not

limited to: 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 / SafetyNursing 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. 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 ConcernsContinuous monitoring of oxygen saturationCardiac rate and rhythmBlood pressureRespiratory rateLevel 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 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 Patient monitoring Reportable conditions Side effects of sedation Benefits of sedation Medications

Monitoring During Moderate Sedation

Heart rate, blood pressure, breathing, oxygen level and alertness are monitored throughout and after the procedure

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 2 points

of Pre-Aldretti score within one hour)

Nursing Management Personnel Equipment Medications Medication reversal agents Management parameters Complications

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

Medications used for Sedation and Analgesia

Midazolam (Versed)

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 cysto-urethrogram (VCUG), CT scan, MRI

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)

Chloral hydrate Classification: Sedative/Hypnotic, Non-

barbiturate, no analgesic properties Action: Dosing

Neonate: Oral: 30-75 mg/kg/doseMaintenance 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 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 SurlfateMorphine 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

Meperidine (Demerol)not used much in peds

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)

Fentanyl 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 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 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 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

Reversal Agents Benzodizepine antagonist antidote:

(Romazicon/flumazinil) Naloxone Hydrochloride narcotic antagonist

(Narcan)(Figure out doses before hand, don’t draw up

but be ready)

Flumazenil (Romazicon)Classification: Benzodiazepine antagonistAction: reverse the effects of procedural

sedation and reverses paradoxical reaction◦ 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) 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.

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.

Paradoxical reaction to versed

Post-Procedural Management

Post-Procedural Monitoring

Parameters and accompanying timeframes: 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

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; reversal agents may not outlast sed/opioid drug effects.

- “Emergence phenomena”

Monitoring Discharge Criteria 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

All outpatients must receive post-sedation precautions and be discharged from the area

Written instructions must include: Post procedural complications Activity limitations Bathing instructions Plan for follow-up care:

Emergency numbers Next physician appointment date