2. Analgesia & Conscious Sedation Narges Daliri, M.D., FAAP Consultant, Pediatric Emergency KFSH & RC, Riyadh

3. Objectives Establish definitions. Select patients. Goals of procedure. Discuss the need for institutional protocol. Discuss equipment and staffing. Discuss complications

4. Introduction Children are often brought to medical attention due to painful conditions or they require diagnostic or therapeutic procedures which are painful or produce anxiety. A child’s pain is felt not only by the child but also by the parents. Presence and severity of pain in infants and children is underestimated by H.C. providers.

5. History of Inadequate Treatment “Brutane”, until recently, was the analgesic and sedative most often used: –total immobilization by several adults and a papoose via brute strength. Paris PM. Amer J Emerg Med 1989

6. Reasons For Inadequate Analgesia/Sedation No ideal sedative. Fear of side effects. Fear of addiction. Inadequate training.

7. Analgesia Patient experiences relief from pain without sedation.

8. Non Pharmacological Intervention Child Life Programs: –Pre-procedural teaching and support. –Guided Imagery. –Distraction. (Bubbles, Music, Books)

9. Such programs: Relieve stress and anxiety associated with an E.D. visit. Decrease upset behavior. Decrease medication requirement. Improve staff efficiency. Improve patient/parent satisfaction.

10. Local Anesthesia One of the most basic aspects of pain control.

11. Local Anesthetics Lidocaine TAC LET EMLA

12. Lidocaine Available forms: –Viscous (2% & 4%) - Aerosol (1% spray) –Gel (2%) –Solution 0.5% (0.5mg/ml) 1% (10mg/ml) 2% (20mg/ml) –Max. dose 5mg/kg –Mixed w/ epinephrine provides vasoconstriction, delayed absorption, decreased lidocaine toxicity. –Mixed w/ NA bicarb. (9:1) Increases ph, decreases burning sensation.

13. TAC Tetracaine, Adrenaline, Cocaine Indication: Wound repair Route: Topical Onset: 10 - 15 min. Duration: 1 hr. Advantage: Painless application Disadvantage: No M. membrane, No end arterioles. –Dose: 1.5 ml/kg of dilute solution.

14. LET Lidocaine, Epinephrine, Tetrocaine Indication: Wound repair. Route: Topical Onset: 30 min. Duration: 60 min. Advantage: Painless application. Disadvantage: No end arteriols. Max Dose: 3 ml

15. EMLA Cream Lidocaine, Prelocaine Indication: Dermal analgesia. Route: Transdermal Onset: 60 min. Duration: 3 – 4 hrs. Advantage: Painless application. Disadvantage: Prolonged onset, meth hem.

16. Pure Analgesics Aspirin (10 mg/kg) P.O., rectal. Acetaminophen (10–15 mg/kg) P.O., rectal. Ibuprofen (5–10 mg/kg) P.O. Ketorolac (Toradol) (0.8 mg/kg followed by 0.4 mg/kg q6 hrs. IV or IM.

17. Sedative Analgesics Morphine (0.1-0.2 mg/kg) I.V., I.M., S.C. Meperidine (1-2 mg/kg) I.V., I.M. Codeine (1 mg/kg) P.O. Fentanyl

18. Fentanyl (Sublimaze) Synthetic opioid. Rapid onset. IV, IM, PO (OTFC) Dose 1 - 2 mcg/kg, Titrate to max of 5 mcg/kg. Peak effect 1 - 10 min. Duration of action 1 - 2 hours. Side effects. –Chest wall rigidity, larygospasm. –Vomiting (with citrate lollypops).

19. Conscious Sedation

20. Definition A medically controlled state of depressed consciousness that allows patients to maintain: –protective reflexes –patent airway independently –appropriate response to verbal and physical stimuli

21. Goals of Sedation Guard patient safety. Minimize pain of procedure. Minimize fear and anxiety. Control behavior. Provide amnesia.

22. Indications Painful or anxiety producing procedures. Benefits outweigh the risks.

23. Level of Consciousness Awake Analgesia Anxiolysis Hypnosis “Conscious Sedation” Deep Sedation General Anesthesia The Spectrum of Sedation Patients may travel quickly in either direction along this spectrum! Protective Reflexes Potential Loss Potential Loss PresentTotal LossPresent ED/Transport Mgmt

25. Indications –Fracture, dislocation reduction. –Pediatric Gyne.Exam –F.B. removal. –Laceration repair. –Others

26. Equipment Continuous monitoring: –Level of consciousness. –Pulse oximetry. –Hemodynamics. Resuscitative drugs including O2. Antidotes Airway equipment. Suction

27. Staffing Staff physician skilled in airway management. –To perform H & P, informed consent. R.N. independent observer. –To monitor patient.

28. Continuous Pulse Oximetry Emergency meds, O2 suction and airway equipment available Personnel #2 (Monitors Patient) Personnel #1 (Performs Procedure) Vital SignsBaselineQ 5 min.Q 15 min. *Consent *H & P *Records meds. & Dosages *Discharge Instructions Before Procedure During Procedure After Procedure Sedation Protocol * = Present * * ** **

29. KFSH Conscious Sedation Policy There must be a documented evaluation of the patient’s anesthetic risk prior to administration of conscious sedation using the ASA rating.

31. Routes Of Administration Transmucosal –Oral –Nasal –Rectal I.V. I.M.

32. The Ideal Sedative Effective Easy and painless to administer. Quick and predictable in onset and duration of action. Without side effects. THE IDEAL SEDATIVE DOES NOT EXIST!

33. Pure Sedative Agents Benzodiazepines –Quick onset of action. –Anxiolytic –Muscle relaxant. –Amnestic

34. Side Effects Respiratory depression with rapid infusion. Hypotension Paradoxical inconsolability (up to 12%)

35. Midazolam (Versed) Rapid onset. Short duration 20 - 30 minutes. Dose IV 0.1mg/kg max. 5mg., onset 2 - 3 min. Oral 0.5mg/kg, onset 20 - 25 min. Intranasal 0.4mg/kg, onset 15 - 20 min. Rectal 0.5mg/kg, onset 5 - 10 min.

36. Other Pure Sedatives Valium Lorazepam Pentobarbitol Thiopental Chloral Hydrate

37. Pentobarbitol (Nembutal) Dose, 2 - 6 mg/kg IV Duration of action, 2 - 3 hours. Side effects Respiratory depression. Hyperactivity

38. Chloral Hydrate May be administered PO or PR. No need for IV. Dose, 60 - 120 mg/kg. Best tolerated if given 75mg/kg initially repeated 25 mg/kg X2. Onset 20 - 30 min. Side effects Respiratory depression. Arrythmias Prolonged sedation. Hyperactivity / Vomiting

39. Propofol Experience in emergency department limited. Short acting, nonopioid sedative hypnotic. Dose, 1 - 2 mg/kg IV over 1 - 2 min followed by infusion of 6mg/kg/hour. Duration, 8 - 11 min. Side effects Deeper sedation. Cardiorespiratory depression. Pain at injection site. Contraindicated in patients with hypersensitivity to eggs.

40. Ketamine Has been used over the past 20 years in the ED with success and efficacy. Derivative of phencyclidine. Provides analgesia, sedation, amnesia. Protective airway reflexes preserved. Decreases bronchospasm.

41. Dose –IV 0.25 to 1 mg/kg loading dose followed by 0.5mg/kg q 3 - 5 min. –IM 4 mg/kg –PO 10mg/kg –Onset of action. 1 minute. –Duration of action. 20 - 30 min. Concomitent meds. –Atropine 0.01mg/kg IV. –Glycopyrrolate 5 mcg/kg IV. –Midazolam 0.05mg/kg IV.

42. Side effects. –Increased secretions. –Increased HR and BP. –Emergence phenomenon. –Emesis –Increased intracranial and intraocular pressure.

43. Contraindication –Patients < 3 month old –Glaucoma –Thyroid disorder. –Psychosis –Head injury –Chronic lung disease.

44. Nitrous Oxide Colorless, odorless gas. Used 50/50 mixture with O2. Safe and effective. Wash-out with 100% O2 for 5 minutes. Patient controlled titration. (Demand Valve) Onset of action, 3 - 5 minutes. Duration 3 - 5 minutes.

45. Action –Mild analgesia. –Sedation, amnesia. –Anxiolytic –Detached attitude towards pain. Side Effects –N. & V. –Agitation –Diffusional Hypoxia

46. Contraindication –Impaired mental status. –Pregnancy –Pneumothorax –Bowel obstruction. –Children < 5 years. –Full stomach.

47. Reversal Agents Naloxone –Dose for reversal. IV or IM Titrate 0.01 - 0.1 mg/kg to desired effect. May need multiple doses. Onset of action 1 - 2 min. Duration of action 20 - 60 min.

48. Flumazenil –Dose IV or IM Pediatrics 0.01 - 0.2 mg/kg (max. 0.2mg) May be repeated. Half dose q 1 min. Adults 0.2 mg bolus to total 1mg. May repeat q 10 min. Onset of action 1 - 5 min. Duration of action 20 - 60 min.

49. Management of Complications Respiratory Depression –Airway and breathing techniques Laryngospasm –Succinylcholine and intubation Hypotension –Fluid bolus Chest wall rigidity –Narcan usually effective –Succinylcholine and intubation

50. Patient Discharge Criteria Return to baseline verbal skills. –Understand and follow directions. –Appropriately verbalize. Return to baseline muscle control function. –If infant can sit up unattended. –Children can walk unattended. Return to baseline mental status. Patient or responsible person with patient can understand discharge instructions.

51. Discharge Instructions Your child has been given some type of sedative or pain medication as part of his or her ED visit today. Medications of this type can cause the child to be sleepy, less aware, not think clearly, or more likely to stumble or fall. Because of this he or she should be watched closely for the next eight hours. In addition, please observe the following precautions: No eating or drinking for the next two hours. If your child is an infant he or she may be fed half a normal feeding one hour after discharge.

52. No play that requires normal childhood coordination, such as bike riding, skating, or use of swing sets or monkey bars for the next 24 hours. No playing without adult supervision for the next eight hours. This is especially important with children who normally are allowed to play outside alone. No bath, showers, cooking, or using possibly dangerous electrical devices such as curling irons without adult supervision for the next eight hours. If you notice anything unusual about your child or have any questions, please call the ED immediately.

53. “Pearls” Be familiar with a few techniques. Be open to new ideas. Use appropriate agent(s) for the situation. Don’t forget the pain of minor medical conditions. Incremental titration of dose to desired effect. Flavorings for oral, sublingual, and nasal preparations. Don’t forget high risk patients. Therapeutic dose is one that accomplishes the therapeutic goal.

54. “Few things a doctor does are more important than relieving pain. Pain is soul destroying…the quality of mercy is essential to the practice of medicine; here of all places it should not be strained.” Angell M. Nejm, 1982