Sedation and Analgesia in Acutely Ill Children Kamal Abulebda Pediatric Critical Care Medicine Riley Hospital for Children at Indiana University Health

Pediatric Sedation & Analgesia The phrase “sedation analgesia” refers to techniques of managing a patient’s pain and anxiety to facilitate appropriate medical care in a safe, effective and humane fashion.

Why Sedation/Analgesia Are Necessary? Ensure patient comfort and pain control Reduce stress and anxiety Facilitate interventions Facilitate mechanical ventilation Reduce O2 consumption Prevent post-ICU psychosis/delirium in older Children

Acquiring A Common Language Agitation: excessive activity associated with internal tension Pain: unpleasant sensory or emotional experience with actual or potential tissue damage Anxiety: sustained state of apprehension with autonomic arousal in response to real or perceived threat Delirium: acute, potentially reversible global impairment of consciousness and cognitive function that fluctuates in severity

MEDICATIONS Sedatives, Analgesics, Antipsychotic Predisposing Conditions Underlying Medical Condition Acute Medical/Surgical Mechanical Ventilation Invasive Procedures Medications ED Environmental Influences (Anxiety, Pain, Delirium) Management of predisposing & Causative Conditions MEDICATIONS Sedatives, Analgesics, Antipsychotic INTERVENTIONS Unresponsive Deeply Sedated Dangerous Agitation Agitation Pain Anxiety Lightly Sedated GOAL?

Ideal Sedative/Analgesic Rapid onset and Rapid recovery Predictable duration No active metabolites Easy to titrate Minimal cardiopulmonary effects Not altered by renal or hepatic disease?? No drug interactions Wide therapeutic index

Define The Goals Is the patient in pain? Is the child anxious? Does the case require immobility? Does the child need to be interactive? Will the effects of administered drugs interfere with the patient exam?

Commonly utilized agents in the ED

Benzodiazepines

Other agents

Neuromuscular blockers

How to pick and choose?

Condition-Specific Approach (at risk population) Hemodynamic Instability/shock Respiratory Failure needing intubation Traumatic Brain Injury Multi-System Trauma Asthma Seizure

Hemodynamic Instability/shock Special considerations: High risk of worsening hemodynamics compromise using certain agents Altered cardiac output and SVR Potential adrenal suppression

Preferred agents Sedative: Ketamine 1-3 mg/kg (increases catecholamine release, may improve hemodynamics) Fentanyl 2-3 mcq/kg +/- Atropine if < 12 months of age Rocuronium Vecuronium

Use with Caution Succinylcholine; risk of hyperkalemia, bradycardia and arrhythmia Etomidate: potential risk of adrenal suppression Barbiturates/propofol/Benzo: worsening hypotension and depressed CO

Respiratory Failure needing intubation Special considerations: Risk of hypoxemia Increased secretions

Preferred agents Sedative: Ketamine 1-3 mg/kg (potential risk of increased secretions) Etomidate 01-0.3 mg/kg Fentanyl 2-3 mcq/kg Versed 0.1 mg/kg (if hemodynamically stable) Rocuronium Vecuronium

Traumatic Brain Injury Special considerations: Increased Intracranial pressure Increased risk of hemodynamic instability Increased risk of seizure

Preferred agents Sedative: Ketamine 1-3 mg/kg (theoretical risk of increased ICP is not proven) Propofol 1-2 mg/kg (if hemodynamically stable) Others (Etomidate, thiopental, lidocaine) Rocuronium Vecuronium

Use with Caution Succinylcholine Risk of increased ICP!

Multi-system Trauma Special considerations: Risk hemodynamic instability Risk of muscles injury Risk of hyperkalemia

Preferred agents Sedative: Ketamine 1-3 mg/kg (theoretical risk of increased ICP is not proven) Etomidate 0.1-0.3 mg/kg (if hemodynamically stable) Others (Fentanyl, Propofol, thiopental, lidocaine) Rocuronium Vecuronium

Use with Caution Succinylcholine; Increased risk of hyperkalemia and arrhythmias Propofol: if hemodynamically unstable Versed: if hemodynamically unstable

Seizure Sedative: Versed 0.1 mg/kg (anti-seizure property) Ketamine 1-3 mg/kg (anti-seizure property) Propofol 1-2 mg/kg (if hemodynamically stable, anti-seizure property) Others Rocuronium Vecuronium

Asthma Ketamine 1-3 mg/kg (Bronchodilator) Propofol 1-2 mg/kg Versed Fentanyl Rocuronium Vecuronium

Use with Caution Morphine; Increased risk of histamine release

Opioid Crisis

Summary Providing safe and effective sedation/analgesia is the ultimate goal Many sedative agents available and utilized for the acutely ill pediatric population Layers of complexity disease process, physiology and organ failures largely impact the drug of choice

Questions