pediatric sedation and analgesia jan chandler rn,msn, cns, cpnp
TRANSCRIPT
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Pediatric Sedation and Pediatric Sedation and AnalgesiaAnalgesiaJan ChandlerRN,MSN, CNS, CPNP
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PSAPSAProcedural sedation and
analgesia (PSA) refers to the pharmacologic techniques of managing a child’s pain and anxiety.
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AAP definition 1992AAP definition 1992Referred to as “conscious
sedation”A depressed state of
consciousness where the patients were able to retain protective reflexes and “respond appropriately to stimuli”.
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Procedural Sedation Re-Procedural Sedation Re-defineddefinedAmerican 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”
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Four Levels of SedationFour Levels of SedationJCAHO and American Society of
Anesthesiologist described the 4 levels of sedation.◦Anxiolysis◦Moderate Sedation◦Deep Sedation◦General Anesthesia
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Minimal SedationMinimal SedationAnxiolysis or minimal sedation
refers to a drug-induced state in which cognitive and motor function may be impaired.
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Moderate SedationModerate SedationModerate sedation is a state of
moderate sedation in which a child responds purposefully to verbal commands with or without light tactile stimulation.
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Deep SedationDeep SedationDeep sedation and analgesia is a
drug induced depressed level of consciousness in which children respond purposefully only to repeated or painful stimulation.
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General AnesthesiaGeneral AnesthesiaGeneral anesthesia refers to the
drug induced loss of consciousness in which there is no response to painful stimulus.
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Sedation for CooperationSedation for CooperationMRICT scanEcho-cardiogram
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Sedation for Painful Sedation for Painful ProceduresProceduresLumbar punctureBone marrow aspiration / biopsyRenal biopsyChest tube insertionCentral line insertion
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Sedation for Emergency Sedation for Emergency ProceduresProceduresIncision and drainageFracture reduction / splintingRepair of lacerations
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Goals of SedationGoals of SedationMood alteration in order to allay the
patient’s fear and anxietyMaintenance 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
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Sedation and Analgesia Sedation and Analgesia GoalsGoals
Achieve adequate sedation with minimal risk
Minimize discomfort and painMinimize negative psychological
response by providing anxiolysis, analgesia, and amnesia
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Monitoring and AssessmentMonitoring and AssessmentKey ElementsKey Elements
Pre-procedural criteriaManagement during sedation Post-procedure sedation assessmentRelease from
observation/dismissal/discharge criteria
Patient/child education and discharge instructions
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Pre-procedural Pre-procedural ASA patient classificationPre-procedural criteriaFeeding guidelinesProcedure / Site verification and
time out
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ASA ClassificationsASA 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
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Pre-procedural CriteriaPre-procedural CriteriaHistory and Physical Informed consentNPO statusBase-line vital signsHeight and weightAdequate staffingEmergency equipment
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Health AssessmentHealth AssessmentHeight / weight in kilogramsVital signs including blood pressureNPO status AllergiesCurrent MedicationsSystemic diseases or genetic
conditionsAbility to intubated in the event of an
emergency: size of jaw and ability to open mouth
History of heart murmur or asthma
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Informed ConsentInformed ConsentIn 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.
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NPO GuidelinesNPO Guidelines
Age Duration 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 hours 2 hours
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NPO GuidelinesNPO GuidelinesBreast 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”
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JCAHO StandardsJCAHO StandardsProcedure /Site VerificationMarking the operative siteTime Out before procedure
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BRN Scope of PracticeBRN Scope of PracticeNurse Practice ActIt 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.
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RN Responsibilities / RN Responsibilities / MedicationsMedicationsThe 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
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RN Responsibilities / RN Responsibilities / SafetySafetyNursing 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.
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RN Safety ConcernsRN Safety ConcernsContinuous monitoring of oxygen
saturationCardiac rate and rhythmBlood pressureRespiratory rateLevel of consciousnessImmediate availability of an emergency
cart which contains resuscitative and antagonist medications, airway and ventilatory equipment (defibrillator , suction equipment, means to administer 100% oxygen.
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Institution ResponsibilitiesInstitution ResponsibilitiesThe 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.
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Management During Management During ProcedureProcedurePatient monitoringReportable conditionsSide effects of sedationBenefits of sedationMedications
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Monitoring During Moderate Monitoring During Moderate SedationSedation
Heart rate, blood pressure, breathing, oxygen level and alertness are monitored throughout and after the procedure
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Reportable ConditionsReportable Conditions
Oxygen saturation less than 90% or 3% decrease from baseline
Change in vital signs of 20% or moreRespiratory depression or distressCardiac dysrhythmiasDeep sedation or loss of consciousness Inadequate sedation and/or analgesic effect Interventions and patient responseFailure to return to baseline status within one
hour
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Nursing ManagementNursing ManagementPersonnelEquipmentMedicationsMedication reversal agentsManagement parametersComplications
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Equipment/Supplies Needed for SedationEquipment/Supplies Needed for Sedation
Pulse oximeterCardiac monitor (if CV
disease or arrhythmias detected or anticipated)
Blood pressure cuffCrash cart in vicinityDefibrillatorSuctionEmergency drugs and
resuscitation equipment
Ambu bag & maskSuction (device and
Yaunker catheter)O2 tubing & maskPatent IV siteReversal agents **
at bedsideOral/nasal airway
and ET tube of appropriate size
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Medications used for Medications used for Sedation and AnalgesiaSedation and Analgesia
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Midazolam (Versed)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
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Versed DosingVersed DosingMidazolam can be given orally,
intravenously, intra-nasally or rectally◦ Dosing:
Neonate dose: IV 0.05-0.2 mg/kg Children dose: Oral: 0.2-.04 mg/kg (max
dose 15 mg) IM: 0.08mg/kg IV: 0.003-0.05 mg/kg (max dose 2.5 mg)
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Chloral hydrateChloral hydrateClassification: Sedative/Hypnotic,
Non-barbiturate, no analgesic properties
Dosing◦Neonate: Oral: 30-75 mg/kg/dose
Maintenance dose: 20-40 mg/kg/dose
◦Children: Oral 25-100 mg/kg/dose (max dose of 1 gm for infants & 2 gm for children)
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Morphine SulfateMorphine SulfateClassification: Narcotic analgesicAction: opium-derivative, narcotic
analgesic, which is a descending CNS depressant. Immediate pain relief lasts up to 4 to 5 hours.
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Morphine SurlfateMorphine SurlfateMorphine dosing
Neonate : IV 0.05 mg/kg **Neonates may require higher dose range- (0.1 mg/kg)
Children: Oral: 0.1-0.3mg/kg IV: 0.03-0.05 mg/kg (max
dose 10 mg/dose) Adolescents: Oral 5-8mg/dose IV: 3-4 mg/dose
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Meperidine (Demerol)Meperidine (Demerol)
Classification: Narcotic AnalgesicAction: 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)
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FentanylFentanylClassification: 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
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KetamineKetamineClassification: 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.
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KetamineKetamineDosing
◦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
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Reversal AgentsReversal AgentsBenzodizepine antagonist
antidoteNaloxone Hydrochloride narcotic
antagonist
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Flumazenil (Romazicon)Flumazenil (Romazicon)Classification: Benzodiazepine
antagonistAction: 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: 0.0005-0.01 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)
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Naloxone (Narcan)Naloxone (Narcan)Classification: Narcotic
antagonistUses: narcotic overdose, post-
operative narcotic depressionDosing
◦Neonate: 0.1 mg/kg/dose◦Children IM/IV/SC: 0.01 -0.1 mg/kg
May repeat dose every 2-3 minutes (max dose is 2 mg/dose.
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Allergic ReactionsAllergic ReactionsNursing 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.
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Post-Procedural Post-Procedural ManagementManagement
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Post-Procedural Post-Procedural MonitoringMonitoring
Parameters and accompanying timeframes:◦Monitor every 15 minutes post-
procedure until: child sips clear fluids child returns to prior mobility status
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Post-Procedural Post-Procedural MonitoringMonitoring
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”
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Monitoring Discharge Monitoring Discharge CriteriaCriteriaThe 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
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Outpatient ConsiderationsOutpatient 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