PEDIATRIC SEDATION PEDIATRIC PAIN CONTROL

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1 PEDIATRIC SEDATION PEDIATRIC PAIN CONTROL Ghazala Q. Sharieff, MD, FAAEM, FACEP, FAAP Underused Concern about respiratory depression Easy to overlook expression of pain in infants and small children Length of stay and nursing time is increased if sedation is used Underuse of analgesia Alexander J. Ann Emerg Med 2003 Retrospective chart of 180 pts with isolated long bone fractures or second and third degree burns 96 pts 6 months-24months ( mean 16.3 months) 84 pts 6-10 years of age (mean age 84.6 months) When pts did receive narcotic meds they were correctly dosed Pts in young age group received no analgesia more than the older age group- 64.5% vs 47.6% All fx-no meds 76.6% vs 48.8% Displaced fx-55% vs 22% Burns-no meds 50% vs 25% ASSESSMENT OF PAIN IN PEDIATRICS Assessment of physiologic response Utilization of pain- analogue scales line drawings of faces with different facial expressions 1

2 NEWBORN PAIN ASSESSMENT The Premature Infant Pain Profile (PIPP) uses physiologic indicators and facial expressions (such as the nasolabial furrow, tightly closing the eyes and the brow bulge) to evaluate pain. -The Neonatal Infant Pain Scale (NIPS) uses crying, arm and leg movement, state of arousal, crying and facial expressions. NEWBORN PAIN ASSESSMENT -CRIES scale specifically addresses Crying, Requirement for oxygen supplementation ( for SaO2 > 95%), Increases in heart rate and blood pressure, facial Expression and Sleeplessness. OTHER INDICATORS OF PAIN Other signs of pain include pallor, flushing, diaphoresis, dilated pupils, hyperglycemia, alterations in sleep and wakeful states, fussiness or listlessness, limb withdrawal, arching or thrashing movements. NON-DRUG METHODS Kangaroo Care Breast feeding or suckling Glucose administration ( 12-50%) 2

3 Newborn pain reduction Gradin M. Pediatr newborns undergoing venipuncture 91 received EMLA on skin and oral placebo 102 received 1cc of 30% glucose orally placed by syringe in the mouth with placebo on skin Staff or family encouraged to use pacifiers or fingers in baby s mouths Premature Infant Pain Profile (PIPP) scale used Newborn pain reduction Gradin M. Pediatr 2002 PIPP scores were lower in the glucose group (4.6 vs 5.7 in EMLA group) less crying in first 3 minutes- 1s median vs 18s in EMLA group 19.3% had pain in glucose group ( PIPP>6) vs 41.7% in EMLA group TOPICAL ANALGESIA LET Lidocaine 4% gel, epinephrine 1:2000, tetracaine 0.5% Good for superficial lacerations on face/scalp Do not use on less vascular areas LET SOLUTION VS GEL? Resch K et al. Ann Emerg Med kids with facial or scalp lacerations randomized to receive either LET gel or solution Blinded, randomized controlled trial No difference in initial adequacy of anesthesia between the two groups Significant difference in complete anesthesia Gel 85%, solution 76%, fewer pts with partial anesthesia 5% versus 21% in solution group 3

4 Topical anesthetics in triage? Priestly S. Ann Emerg Med 2003 Children aged 1-10 years of age with simple lacerations Excluded if there were wounds to digits, bone, over 6 years of age, allergy to anesthetics 84 randomized to receive ALA ( adrenaline, lidocaine, amethocine) and 77 received adrenaline at triage Time from triage to discharge documented Topical anesthetics in triage? Priestly S. Ann Emerg Med sutured, 84 glued, 6 steristrips, 6 no closure Median time to treatment: ALA- 77 minutes Control-108 minutes EMLA 2.5% lidocaine 2.5% prilocaine Useful for painful procedures on intact skin Must apply 60 minutes before procedure 4

5 ELA-Max vs EMLA Eichenfeld et al. Pediatrics children who were undergoing repeat venipuncture were enrolled. Received either EMLA or ELA-Max- 4% liposomal lidocaine Liposomes work by facilitating drug absorption and prevent rapid metabolism. Lipsosme encapsulated lidocaine allows meds to remain in epidermis after application Pain assessed using a VAS and the parent s and blinded research observer s observed behavioral distress score ELA-Max vs EMLA Eichenfeld et al. Pediatrics 2002 No difference between ELA-Max and EMLA groups 30 application of ELA-Max without occlusion is equivalent to 60 of EMLA with occlusion INFILTRATIVE ANALGESIA Lidocaine Maximum dose: 4-5mg/kg without epinephrine; 7mg/kg with epinephrine Do not use on distal extremity, nose,penis or pinna of the ear. Bupivicaine Maximum dose: 2-3mg/kg 4X more potent than lidocaine Duration up to 7 hours with epinephrine 5

6 Procedural Sedation and Analgesia (PSA) ACEP developed the term PSA PSA is defined as a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allow the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function. DEFINITIONS 1. Minimal sedation (Anxiolysis) 2. Moderate sedation (CS) -patent airway with adequate ventilation and cardiovascular function. 3. Dissociative Sedation 4. Deep sedation -partial or complete loss of protective reflexes, inability to maintain a patent airway and adequate ventilation 5. General Anesthesia PRE-SEDATION ASSESSMENT PMH Allergies Medications NPO status Previous experience with anesthesia NPO STATUS For non-emergent procedures Prefer no intake for 6 hours For emergency purposes: Solids: 3-4 hours, liquids 2 hours 6

7 NPO STATUS Agrawal D Ann Emerg Med % of 1114 patients with a median age of 5.4 years ( 5 days to 31 years) were not fasted in accordance with the AAP/ASA guidelines. No association between preprocedural fasting state and adverse events. EQUIPMENT ECG monitor/ Code cart available pulse oximeter BP monitor Suction Bag-valve mask/ ETT tubes Nasal cannula Narcan/ flumazenil Combination Regimens 1. Midazolam mg/kg IV 2. Fentanyl 2ug/kg IV 1. Midazolam 0.05 mg/kg IV 2. Morphine 0.1 mg/kg IV 1. Midazolam 0.05 mg/kg IV 2. Atropine 0.01 mg/kg IV 3. Ketamine 1 mg/kg IV 1. Midazolam 0.05 mg/kg IM 2. Ketamine 4 mg/kg IM 3.Atropine 0.01mg/kg 1. Fentanyl 0.001mg/kg IV 2. Propofol 0.05 mg/kg IV 1. Ketamine 0.5mg/kg 2. Propofol 1mg/kg ** pilot study-20 pts, Agent Combinations Pairing of narcotic and sedative for painful procedures.adverse effects such as respiratory depression increased greater than sum of either agent alone. Give 0.05 mg/kg midazolam over 1 minute then narcotic over 1 minute. Narcotic may be repeated as needed to effect. Observe for apnea. The need for midazolam in ketamine regimens is considered questionable by some authorities. Midazolam 0.05 mg/kg IV over 1 minute then ketamine 1 mg/kg over 1 minute. All IM drugs may be given in the same syringe(ketamine,midazolam,atropine) May substitute 0.5-1(0.75) mg/kg of po midazolam 15 minutes before ketamine. Narcotic is administered first. If necessary this is followed with 0.05 mg/kg of propofol titrated in over 1-2 minutes. repeat dose of 0.25mg/kg K or 0.5mg/kg P ANALGESIA FOR BRIEF, PAINFUL PROCEDURES Fentanyl 100X more potent than morphine Onset: 2 minutes Duration: 30 minutes Initial dose: 2-3ug/kg IV ** Intubating dose is 5ug/kg Complications: Respiratory depression, chest wall rigidity, bradycardia 7

8 ANALGESIA FOR BRIEF, PAINFUL PROCEDURES Nitrous Oxide Disssociative, euphoric, sedative agent Onset: 1-2 minutes Initial Dose: 30-50% mixture with O2 Administration: self-administered Contraindications: Pneumothorax, eye injuries, obstructed viscus, ALOC 8

9 CASE STUDIES A 4 year-old patient sustained a large tongue laceration that needs repair. What is your choice for sedation? How long should the patient be NPO before sedation? CASE STUDIES A 4 year-old male was sedated with IM ketamine. He becomes stridorous. What important history should have been obtained? What should you do now? ANALGESIA FOR BRIEF, PAINFUL PROCEDURES Ketamine- (dissociative/sedative) Onset: 1-5 minutes depending on route Duration: IV-10 minutes; IM minutes Initial Dose: IV 1 mg/kg: IM 4mg/kg Oral 5-10 mg/kg 9

10 KETAMINE: COMPLICATIONS Laryngospasm-esp age<3 months Increased ICP & intraocular pressure Hypertension, Hallucinations, Increased salivation use atropine 0.01mg/kg Glycopyrrolate mg/kg (0.25mg) SAFETY OF KETAMINE? Green S. Ann Emerg Med 1999 IM Ketamine for pediatric sedation 1,022 cases. Data forms completed for 431 pts 4 mg/kg IM. Adequate sedation in 98% of pts Transient airway comp 1.4% Apnea (2), laryngospasm (4), airway malalignment (7), resp depression (1) Emesis 6.7%, no aspiration Mild agitation 17%; Mod-severe 1.6% SAFETY OF KETAMINE? Green S. Ann Emerg Med 1999 Ketamine is very safe Remember to give atropine 0.01mg/kg (min 0.1mg, max 0.5mg) Contraindications:? Head injury Intraocular pressure elevation Preceding URI => laryngospasm Poorly controlled seizures, psychiatric disorder Age less than 3 months ( laryngospasm) KETAMINE AND MIDAZOLAM Sherwin T et al. Ann Emerg Med kids between 12 months and 15 years enrolled in this blinded, RCT study IV Midazolam vs placebo during ketamine sedation Sedation efficacy, adverse effects, and recovery time were similar Recovery agitation similar between two groups Pre-procedural agitation moderately correlated to post-procedural agitation 10

11 KETAMINE AND MIDAZOLAM Sherwin T et al. Ann Emerg Med 2000 Mean pt age was 7.3 years Midazolam given after ketamine Pre-procedural agitation was related to postprocedural agitation, so? Versed should be given before the ketamine ANALGESIA FOR LONGER, PAINFUL PROCEDURES Morphine Onset: 5-10 minutes Duration: 3-4 hours Initial Dose: 0.1mg/kg IV Complications: respiratory depression, hypotension ANALGESIA FOR LONGER, PAINFUL PROCEDURES Demerol 10X less potent than morphine Onset: Rapid IV; minutes IM Duration 2-3 hours Initial Dose:1mg/kg IV/ IM Complications: respiratory depression, hypotension, seizures 11

12 SEDATION FOR BRIEF, NONPAINFUL PROCEDURES Midazolam Benzodiazepine with amnestic property Onset: 2 minutes IV; IM, PR, PO, IN Duration: 30 IV; 45 IM, PR, IN, PO Initial Dosage: 0.1mg/kg IV mg/kg PO, IN, PR Complications: apnea, hypotension, paradoxical agitation Pentobarbital Rapid-acting Short duration Titratable mg/kg IV (maximum, 200 mg) Rectal and IM dose 3-5mg/kg Useful for diagnostic studies, eg, CT scans MIDAZOLAM VS PENTOBARBITAL FOR HEAD CT Moro-Sutherland DM. Acad Emerg Med pts enrolled over a 2 ½ year period. Mean age 26 months 29 received pentobarbital (mean dose 3.75mg/kg) and 26 received Versed ( mean dose 0.2mg/kg) 97% of pts in pentobarbital group were scanned successfully with duration of sedation up to 86, mean induction time of 6 12

13 MIDAZOLAM VS PENTOBARBITAL FOR HEAD CT Moro-Sutherland DM. Acad Emerg Med 2000 Only 19% of Versed group ( 5 pts) successfully scanned, 12 subsequently sedated with pentobarbital. 14% ( 4 pts) in pentobarbital group had desat to 90-94% blow-by O2 was the only intervention needed MIDAZOLAM VS PENTOBARBITAL FOR HEAD CT Moro-Sutherland DM. Acad Emerg Med 2000 Small study Unblinded so observer may have been biased Midazolam has a reported 1% incidence of paradoxical agitation-especially in young children Range of sedation time was minutes with pentobarbital Start with 2 mg/kg of pentobarbital over 30s, wait 1 minute and give additional 1mg/kg at 1 minute intervals until a maximum dose of 5 mg/kg is reached Methohexital (Brevital) Short acting barbituate Dose: 1mg/kg up to 50mg IV; rectal 15mg/kg of 1-2% solution Onset 45 seconds with IV, minutes with PR Duration minutes Contraindicated in epileptic patients Methohexital and CT scans Sedik H etal. Arch Pediatr Adolesc Med patients undergoing CT scan IV methohexital doses ranges from 0.5 mg/kg to 2.0 mg/kg (mean +/- SD, 1 +/- 0.5 mg/kg). Onset of sedation was rapid (mean 1 +/- 0.4 minutes), sedation was brief (mean 12 +/- 5 minutes), and the mean length of the drug's effects was 14 +/- 6 minutes. Sedation was effective in most cases, and only 3/55 patients had a transient drop in 02 saturation 13

14 ETOMIDATE Ultra short acting sedative hypnotic Protects ICP Does not cause hypotension Already used for RSI- 0.3mg/kg Dose: mg/kg for sedation Cortisol suppression, myoclonic jerks Pain can be decreased by using larger vein ETOMIDATE FOR HEAD CT s Kienstra AJ etal. Pediatr Emerg Care pts 6months 6 years of age 17 etomidate, 33 pentobarbital total Etomidate 0.3mg/kg- 57%, 0.4mg/kg- 76% Pentobarbital up to 5mg/kg Success rate 97% Longer induction time, longer sedation time Etomidate for head CT s Baxter A etal. PEM care CT scan sedations. Age range 6-83 months 446 Etomidate only 396 cases-pentobarbital + midazolam Propofol in the majority of other cases Etomidate given as a bolus of 0.3mg/kg after 0.5mg/kg of lidocaine (25mg max) is given to mitigate burning Additional aliquots of 0.15mg/kg given within 1 minute of initial dose X2 Etomidate Liddo. Annals Emerg Med 2006 Randomized, double-blind 100 kids, 2-18 yrs, ED orthopedic procedures Fentanyl and then etomidate 0.2mg/kg or midazolam 0.1mg/kg Adequate sedation: etomide 92% vs midazolam 36% Recovery: etomidate 12mins vs midazolam 24mins Desaturation, vomiting similar Myoclonus was 11% in etomidate 14

15 Propofol Extremely potent sedative Available only for IV administration 0.5-1mg/kg bolus then ug/kg/min infusion Or repeat bolus of 0.5mg/kg Rapid onset (10-15 seconds) Short half-life (8-15 minutes) Causes respiratory depression and hypotension Contraindicated in patients with egg and soy allergy Propofol Anderson. Annals Emerg Med, kids, 2-17 yrs, ED ortho procedures Morphine, then fentanyl and propofol 1mg/kg Additional propofol 0.5mg/kg Successful procedures, 98% 2 needed open fracture repair Adverse airway events, 11% 4 jaw-thrust, 6 O2, 1 BVM (<30 secs) Capnography better than pulse ox Ketamine and propofol Sharieff G. Pediatric Emerg Care 2007 Pilot study of 20 children undergoing fracture reduction 0.5mg/kg of ketamine followed by 1mg/kg propofol Pts could receive narcotics up to 1 hour prior Subsequent dose of either 0.25mg/kg of ketamine or 0.5mg/kg propofol Ketamine and propofol Sharieff G. Pediatric Emerg Care 2007 Only one patient required additional doses and this pt ultimately went to OR for reduction Median time intervals measured from initiation of ketamine injection were 5 minutes to reduction completion, 10 minutes to first purposeful response, and 38 minutes to suitability for discharge! 15

16 PROPOFOL IN KIDS Infusion Pain Tips from Al Sacchetti! Intravenous infusion is stopped and vein is occluded with a finger 1-2 cm proximal to catheter tip. Slow infusion of cc of 1% lidocaine without epinephrine, not to exceed 1 mg/kg. Hold finger occlusion in place for 2 minutes. SEDATION FOR LONGER, NONPAINFUL PROCEDURES ( MRI, EEG) Chloral hydrate Onset: minutes Duration: 3-4 hours Dosage: mg/kg PO/PR; max 2 grams Complications: GI irritation, seizures, cardiac arrhythmia's Rarely used in the ED setting ANTAGONIST AGENTS NALOXONE( Narcan) Dose: mg/kg Indicated for reversal of narcotic agents In chronic drug users, may cause seizures, agitation Titrate reversal slowly to avoid: tachycardia, hypertension, arrhythmia's, and abrupt loss of sedation 16

17 ANTAGONIST AGENTS FLUMAZENIL Dose: not clear in pediatrics, may use 0.01mg/kg up to 0.2mg and titrate to effect. Indicated for benzodiazepine overdose In chronic benzodiazepine users, can cause seizures DOCUMENTATION Vital signs and O2 saturation q5 during sedation, then 30 after last dose given, then q15 X2. Continuous ECG and pulse-oximetry Document all times and routes of administration TIME TO DISCHARGE Newman etal. Ann Emerg Med sedation events, with 184 (13.7%) adverse effects. Most effects occurred during sedation (92%) Serious effects occurred a median of 2 after final medication dose. One hypoxic event at 26, 30 and 40 after final medication-all had previous hypoxia during the peak drug effect TIME TO DISCHARGE Newman etal. Ann Emerg Med 2003 Side effects: Hypoxia, hypotension, stridor, emesis, rash, agitation, dizziness Authors conclude that discharge from the ED may be possible 30 after final sedation medication if no adverse effects have occurred 17

18 DISCHARGE CRITERIA Stable vital signs Oriented with return to pre-procedural state Able to take fluids without emesis Able to ambulate CASE STUDIES A 2 year old female sustained a large leg laceration. She is anesthetized with a total of 8 cc of 1% lidocaine without epinephrine. The patient has a tonic-clonic seizure. What happened? CASE STUDIES SEDATION and ANALGESIA If the patient weighed 12 kg, she was injected with 80 mg of lidocaine. The toxic dose of lidocaine without epinephrine is 4-5mg/kg. Each 1cc of 1% lidocaine contains 10 mg of lidocaine. 18