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

2. 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.

3. 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

4. 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

5. 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?

6. 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

7. 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?

8. Commonly utilized agents in the ED

9. Benzodiazepines

10. Other agents

11. Neuromuscular blockers

12. How to pick and choose?

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

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

15. 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

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

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

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

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

20. 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

21. Use with Caution
Succinylcholine Risk of increased ICP!

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

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

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

25. 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

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

27. Use with Caution
Morphine; Increased risk of histamine release

28. Opioid Crisis

29. 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

30. Questions