Pediatric Sedation and Analgesia
Judy Zier, MD
Last updated 12/96 for content, 9/97 for format
Twenty, twenty, twenty-four hours ago
I wanna be sedated
Nothing to do nowhere to go
I wanna be sedated
the Ramones
Outline
Indications
- control pain - from trauma, post-operative pain, or for painful procedures
- decrease anxiety - hospital environment may provoke anxiety
- decrease motion - for diagnostic procedures (e.g., CT, MRI)
Levels of Sedation
Conscious sedation
- protective reflexes maintained
- patient able to maintain own airway
- appropriate response to stimulation or voice command - e.g., "open
your eyes"
Deep sedation
- cannot respond purposefully to physical or verbal stimulation
- may have partial or complete loss of protective reflexes
- may not be able to maintain a patent airway independently
General anesthesia
- · unconscious
- · cannot respond purposefully to physical or verbal stimulation
- · loss of protective reflexes including inability to maintain
airway independently
Sedation as a continuum
- responsible physician must be prepared to handle next deeper level
of sedation
Each state of sedation carries the risk of the patient slipping into
the next deeper level of sedation; therefore, if conscious sedation is used,
must be prepared to manage a patient in deep sedation
General guidelines - equipment
Must be appropriate for age and size of the patient
- blood pressure and oxygen saturation equipment
- access to positive-pressure oxygen delivery system
- access to emergency cart or kit
General guidelines - documentation
- informed consent and instructions - risks and benefits of sedation
must be explained to parents and consent obtained and documented. Information
must be given to the person responsible for the patient, including objectives
of the sedation, anticipated changes in behavior during and after sedation,
limitations of activities and any dietary precautions and a 24-hour telephone
number for the practitioner or his/her associates (see AAP guidelines).
- patient's recent food and fluid intake - NPO guidelines appropriate
for age should be followed (see AAP guidelines)
- history and physical
- vital signs, oxygen saturation, and level of responsiveness during
sedation
- level of consciousness at time of discharge
General guidelines - personnel
- person doing procedure
- separate person responsible for monitoring
Medications available
Local anesthetics
- lidocaine - overdose may cause seizures, cardiovascular depression;
calculate dose, particularly in small children; maximum recommended dose
= 7mg/kg
- TAC (tetracaine, adrenaline, cocaine) - can be applied topically;
may see toxicity if applied to large mucosal surface which allows rapid
drug absorption; avoid use in areas with limited circulation (e.g., tip
of finger) because of vasoconstrictive properties
- EMLA (eutectic mixture of local anesthetics) - lidocaine plus
prilocaine; absorbed through intact skin; may induce methemoglobinemia
if excessive drug is applied for longer than necessary
Analgesics - non-narcotic
- acetaminophen
- aspirin - avoid with chicken pox or influenza
- nonsteroidal anti-inflammatory agents
- ibuprofen
- ketorolac - may be given IV or IM
Analgesics - narcotic
May cause respiratory depression, particularly when combined with a benzodiazepine;
can be reversed with naloxone (Narcan) 0.01-0.1 mg/kg - however, half-life
of naloxone may be shorter than that of the narcotic, making repeated doses
necessary
- morphine - dose 0.1-0.2 mg/kg IV or IM; good sedation and analgesia;
onset 10 minutes if given IV, 20-60 minutes if given IM; duration of action
3-4 hours; may decrease systemic vascular resistance; may cause histamine
release
- meperidine (Demerol) - dose 1-2 mg/kg IV or IM; onset 15-30
minutes with peak effect 45-60 minutes IV, 90 minutes IM; half-life 3-4
hours; may accumulate toxic metabolites (normeperidine) if given chronically
- fentanyl (Sublimaze) - dose 1-2 mcg/kg IV; rapid onset of action;
opioid effects last 30-45 minutes, but respiratory depression may last
longer; can cause chest wall and glottic rigidity when given rapidly; less
histamine release than morphine; may be given transdermally
- codeine - dose 0.5-0.75 mg/kg; useful for mild to moderate pain;
well absorbed orally
Sedatives - benzodiazepines
Relieve anxiety, provide sedation and amnesia; no analgesic properties;
can be given orally, rectally or IV; respiratory and/or cardiovascular depression
may occur, particularly with rapid administration; may be reversed with
flumazenil 0.002-0.02 mg/kg; may cause agitation and hyperexcitability
- diazepam (Valium)- dose 0.1-0.3 mg/kg; onset of action
IV 1-3 minutes; duration of action 15-30 minutes (anti-seizure) sedative
effects - 18-24 hours or longer
- midazolam (Versed) - dose 0.05-0.1 mg/kg; fast onset (1-5 minutes)
and shortest duration of action
- lorazepam (Ativan) - 0.02-0.05 mg/kg; onset of action IV 15-30
minutes; duration of action 8-12 hours
Sedatives - barbiturates
CNS depression, from mild sedation to deep coma; no analgesic properties;
may cause respiratory depression with loss of protective airway reflexes
at higher doses; may cause cardiovascular depression
- pentobarbital (Nembutal) - dose 2-5 mg/kg; onset of action within
1 minute given IV, 15-60 minutes given orally or rectally; duration of
hypnotic effect 15 minutes given IV, 1-4 hours given orally or rectally
- thiopental (Pentothal) - rapid onset and short duration of action;
causes significant respiratory depression; useful for rapid sequence intubation
Sedatives - other
- chloral hydrate - sedative-hypnotic; no analgesic properties;
dose 20-100 mg/kg po or pr; onset of sleep 30-60 minutes; irregular absorption
may lead to prolonged effect; minimal effects on respiration. Not absorbed
in stomach, so patient with delayed gastric emptying may not get good effect.
- propofol (Diprivan) - dose (0.5-2mg/kg depending on desired
effect) extremely short-acting sedative-hypnotic; continuous infusion required
to maintain sedation; rapidly produces a state of general anesthesia, therefore
should not be used by individuals unskilled in airway management; may cause
hypotension particularly with rapid bolus injection; causes pain at injection
site
Other agents
- diphenhydramine (Benadryl) - antihistamine, with side effect
of sedation, from mild drowsiness to deep sleep; dose 1-1.5 mg/kg orally
or IV; may cause paradoxical excitement
- hydroxyzine (Atarax, Vistaril) - antihistamine, with side effect
of sedation, from mild drowsiness to deep sleep; may cause paradoxical
excitement
- ketamine (Ketalar) - dose 1-2mg/kg, phencyclidine derivative;
provides sedation, amnesia and analgesia; less respiratory or cardiovascular
depression than narcotic/benzodiazepine combination; may cause hypersalivation,
laryngospasm, hypertension, increased intracranial pressure or increased
intraocular pressure; may cause emergence dysphoria; use with anticholinergic
agent such as atropine (decreases secretion production) and a benzodiazepine
(reduces emergence dysphoria)
- DPT - Demerol/Phenergen/Thorazine; slow onset with prolonged
effect; impossible to titrate to effect; may lead to respiratory depression;
can lead to dystonic reactions
Choose agents based on expectations of procedure
- e.g., sedatives only if procedure is not painful, analgesics if pain
is expected
- try to match duration of action to expected duration of procedure
Use only drugs you have experience with and feel comfortable using
This outline is meant for teaching purposes only, drug dosing should
be confirmed by an appropriate resource (i.e. a Pharmacist, AHFS Red Book,
PDR etc.). These durgs should not be used by inexperienced care givers.
Questions or comments regarding this out-line should be directed to
the author at:
This page last updated 9/2/1997 at 1055CDT