Pediatric Sedation and Analgesia Jan Chandler RN,MSN, CNS, CPNP

PSA Procedural sedation and analgesia (PSA) refers to the pharmacologic techniques of managing a child’s pain and anxiety.

AAP definition 1992 Referred to as “conscious sedation” A depressed state of consciousness where the patients were able to retain protective reflexes and “respond appropriately to stimuli”.

Procedural Sedation Re-defined American College of Emergency Physicians re-named “conscious sedation” Procedural sedation’s goal was to medicate patients until they can tolerate unpleasant procedures This sedation was termed “moderate sedation”

Four Levels of Sedation JCAHO and American Society of Anesthesiologist 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.

Moderate Sedation Moderate sedation is a state of moderate sedation in which a child responds purposefully to verbal commands with or without light tactile stimulation.

Deep Sedation Deep sedation and analgesia is a drug induced depressed level of consciousness in which children respond purposefully only to repeated or painful stimulation.

General Anesthesia General anesthesia refers to the drug induced loss of consciousness in which there is no response to painful stimulus.

Sedation for Cooperation MRI CT scan Echo-cardiogram

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

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

Sedation and Analgesia Goals Achieve adequate sedation with minimal risk Minimize discomfort and pain Minimize negative psychological response by providing anxiolysis, analgesia, and amnesia

Monitoring and Assessment Key Elements Pre-procedural criteria Management during sedation Post-procedure sedation assessment Release from observation/dismissal/discharge criteria Patient/child education and discharge instructions

Pre-procedural ASA patient classification Pre-procedural criteria Feeding guidelines Procedure / Site verification and time out

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 Informed consent NPO status Base-line vital signs Height and weight Adequate staffing Emergency equipment

Health Assessment Height / weight in kilograms Vital signs including blood pressure NPO status Allergies Current Medications Systemic diseases or genetic conditions Ability to intubated in the event of an emergency: size of jaw and ability to open mouth History of heart murmur or asthma

Informed Consent In an outpatient procedure a consent will need to be signed by a parent or legal guardian. In and in-patient procedure consent my often be covered by the general hospital consent.

NPO Guidelines AgeDuration 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 hours2 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. An emergency child may require protection of the airway (intubation) before sedation”

JCAHO Standards Procedure /Site Verification Marking the operative site Time Out before procedure

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 ◦ Potential side effects of the medication ◦ Contraindications for the administration of the medication ◦ Amount of medication to be administered

RN Responsibilities / Safety Nursing 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. ◦ Patient should never be left un-attended ◦ Registered nursing functions may not be assigned to unlicensed assistive personnel.

RN Safety Concerns Continuous monitoring of oxygen saturation Cardiac rate and rhythm Blood pressure Respiratory rate Level of consciousness Immediate availability of an emergency cart which contains resuscitative and antagonist medications, airway and ventilatory equipment (defibrillator, suction equipment, means to administer 100% oxygen.

Institution Responsibilities The institution should have in place a process for evaluating and documenting the RNs demonstration of the knowledge, skills, and abilities for the management of clients receiving agents to render conscious 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 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) O 2 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. ◦ Action: 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-operative events. ◦ Suited for procedures that are not especially painful: central catheter placement, VCUG, CT scan

Versed Dosing Midazolam can be given orally, intravenously, intra-nasally or rectally ◦ Dosing:  Neonate dose: IV mg/kg  Children dose: Oral: mg/kg (max dose 15 mg) IM: 0.08mg/kg IV: mg/kg (max dose 2.5 mg)

Chloral hydrate Classification: Sedative/Hypnotic, Non- barbiturate, no analgesic properties Dosing ◦ Neonate: Oral: mg/kg/dose Maintenance dose: mg/kg/dose ◦ Children: Oral mg/kg/dose (max dose of 1 gm for infants & 2 gm for children)

Morphine Sulfate Classification: Narcotic analgesic Action: opium-derivative, narcotic analgesic, which is a descending CNS depressant. Immediate pain relief lasts up to 4 to 5 hours.

Morphine Surlfate Morphine dosing  Neonate : IV 0.05 mg/kg **Neonates may require higher dose range- (0.1 mg/kg)  Children: Oral: mg/kg IV: mg/kg (max dose 10 mg/dose)  Adolescents: Oral 5-8mg/dose IV: 3-4 mg/dose

Meperidine (Demerol) 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 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 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 Naloxone Hydrochloride narcotic antagonist

Flumazenil (Romazicon) Classification: Benzodiazepine antagonist Action: reverse the effects of procedural sedation ◦ 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: 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: 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.

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

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 - “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