Sedation, Analgesia, Neuromuscular Blockade and Withdrawal




INTRODUCTION



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  1. Nonpharmacologic strategies should be used prior to any pharmacologic intervention to reduce pain and anxiety. Sample strategies include, but are not limited, to the following:




    1. Positioning



    2. Massage



    3. Distraction




      1. Music (live or from device)



      2. Technology devices (e.g., video gaming, television, videos, etc.)




    4. Environmental changes




      1. Room temperature



      2. Lighting




    5. Inclusion of family to promote comfort




      1. Story telling



      2. Singing



      3. Soothing touch




    6. Miscellaneous




      1. Bundling (age appropriate)



      2. Non-nutritive suck (age appropriate)



      3. Application/removal of blankets



      4. Application/removal of warm/cool packs



      5. Active and passive range of motion





  2. Topical analgesia




    1. Indications




      1. Minor procedures




        1. Intravenous catheter placement (peripheral or central)



        2. Arterial line catheter placement



        3. Lumbar puncture



        4. Phlebotomy





    2. Types available




      1. Lidocaine and prilocaine




        1. Apply to intact skin with occlusive dressing



        2. Remains on skin 20 to 60 min prior to procedure depending on formulation




      2. Buffered lidocaine




        1. Needle-free pressurized delivery system into the subcutaneous tissue



        2. Allow 2 minutes for maximum anesthesia



        3. 1 mL bicarbonate/9 mL 1% lidocaine




      3. Intradermal lidocaine




        1. Needle injection



        2. Maximum dose of lidocaine




          1. 4.5 mg/kg without epinephrine



          2. 7 mg/kg with epinephrine







  3. Nonopioid analgesia




    1. Indications




      1. Reduce pain



      2. Minor procedures



      3. Facilitate medical therapies





  4. Sedation and analgesia




    1. Indications




      1. Reduce anxiety and pain



      2. Procedures



      3. Facilitate medical therapies



      4. Airway control



      5. Decrease the work of breathing



      6. Decrease oxygen demand





  5. Neuromuscular blocking agents (NMBAs)




    1. Important notes




      1. ALWAYS ensure ability to bag-mask ventilate the patient prior to administration of NMBA



      2. ALWAYS be prepared to manage the airway of a patient receiving NMBA



      3. NEVER administer NMBA to a patient without assuring adequate sedation/analgesia beforehand



      4. Ensure routine monitoring of depth of muscle blockade to reduce subsequent weakness and use minimum effective dose




    2. Indications




      1. Facilitate procedures




        1. Surgical relaxation



        2. Endotracheal intubation



        3. Vascular access




      2. Facilitate medical therapies




        1. Decrease O2 consumption



        2. Prevent shivering (hypothermia)



        3. Reduce metabolic expenditure



        4. Limit mechanical ventilator dyssynchrony



        5. Unconventional modes of ventilation



        6. Transport of patient






  6. Medications (See Tables 15-1–15-6)



  7. Monitoring sedation level




    1. Tools




      1. No adequate scales to measure sedation in children receiving NMBA



      2. State Behavioral Scale (SBS)




        1. Uses progressive stimuli to evaluate level of sedation



        2. Use in critically ill infants and children ages 6 months to 6 years




      3. Comfort Scale




        1. Measures postoperative pain, nonpain distress, sedation, and analgesia



        2. No pediatric age restriction





    2. Titration




      1. Evidence supports nurse-led sedation algorithms are safe



      2. Use minimum effective dose to reduce prolonged sedation





  8. Monitoring for withdrawal syndrome


    During the process of weaning from sedation and analgesia, it is important to monitor for signs of withdrawal.




    1. Variables associated with risk of withdrawal syndrome




      1. Duration of medication therapy



      2. Maximum cumulative dose of medications



      3. Type of opioid (fentanyl and remifentanil associated with more withdrawal than morphine)



      4. Type of sedative



      5. Younger age associated with increased risk of withdrawal syndrome




    2. Tools




      1. Withdrawal Assessment Tool (WAT-1)



      2. Sophia Observation withdrawal Symptoms-scale (SOS)




    3. Strategies for weaning




      1. May transition to alternative medications



      2. May use enteral forms of currently administered medications if available



      3. Ensure monitoring and adequate treatment of intolerable symptoms



      4. Taper one medication class at a time




        1. Taper parenteral narcotic off over 3 days (decrease by 10% every 8 hours)



        2. Then taper sedative off over 5 days (decrease by 20% daily)




      5. Alternate taper (e.g., narcotic taper every Monday and sedation taper every Friday)



      6. Select a wean plan and evaluate patient tolerance of wean; adjust as needed




    4. Medications (see Table 15-7)






TABLE 15-1

Nonopioid Pain Control


































Medication Dose Mechanism
Acetaminophen

IV:


Infants to <2 yr: 7.5 mg/kg/dose IV q6 hr; max of 60 mg/kg/day


Adolescents 2–12 yr <50 kg: 15 mg/kg/dose IV q6 hr; max of 75 mg/kg/day (max 3750 mg/day)


≥50 kg


1000 mg IV q6 hr


PO:


10–15 mg/kg/dose every 4–6 hr as needed; do not exceed 5 doses in 24 hr; maximum: 75 mg/kg/day


Rectal:


Infants and children <12 yr: 10–20 mg/kg/dose every 4–6 hr

 Inhibits the synthesis of prostaglandins in the central nervous system and works peripherally to block pain impulse generation; produces antipyresis from inhibition of hypothalamic heat-regulating center
Ibuprofen

PO:


Infants and children <50 kg: limited data available


Infants <6 mo: 4–10 mg/kg/dose every 6–8 hr; max daily dose: 40 mg/kg/day


≥12 yr and adolescents: 200 mg every 4–6 hr as needed; if pain does not respond, may increase to 400 mg; maximum daily dose: 1200 mg/day

 Reversibly inhibits cyclooxygenase-1 and 2 (COX-1 and 2) enzymes, which results in decreased formation of prostaglandin precursors; has antipyretic, analgesic, and anti-inflammatory properties
Ketoralac

IV:


<2 yr: limited data available


Multiple-dose treatment: IV: 0.5 mg/kg every 6–8 hr, not to exceed 48–72 hr


2–16 years or adolescents >16 yr <50 kg: 0.5 mg/kg every 6 hr; maximum dose: 30 mg/dose, usual reported duration: 48–72 hr; not to exceed 5 days of treatment
Naproxen PO:


  • <60 kg: 5–6 mg/kg/dose every 12 hr;



  • ≥60 kg: 250–375 mg twice daily; maximum daily dose: 1000 mg/day
Lidocaine Local injectable dose varies with procedure, degree of anesthesia needed, vascularity of tissue, duration of anesthesia required, and physical condition of patient. Maximum dose: 5 mg/kg/dose Blocks both the initiation and conduction of nerve impulses by decreasing the neuronal membrane’s permeability to sodium ions.
Lidocaine and epinephrine Local infiltration dosage varies with the anesthetic procedure, but should not exceed 7 mg/kg/dose

Lidocaine: Blocks both the initiation and conduction of nerve impulses by decreasing the neuronal membrane’s permeability to sodium ions.


Epinephrine: Increases the duration of action of lidocaine by causing vasoconstriction, slowing the vascular absorption of lidocaine.





TABLE 15-2

Analgesic Agents for Pain Management or Sedation Adjunct































Medication Dosing Onset and Duration Comments
Fentanyl


  • IV: 1–2 mcg/kg/dose



  • Infusion:



  • 1–2 mcg/kg/hr


  • Onset: 2–3 min



  • Duration: 30–60 min


  • More expensive than morphine but less histamine release



  • Reverse with naloxone



  • Reduce dose when combined with benzodiazepines

Hydromorphone


  • Infants



  • >6 mo, >10 kg



  • IV: 0.01 mg/kg/dose



  • Infusion:



  • 0.003–0.005 mg/kg/hr



  • Children <50 kg IV: 0.015 mg/kg/dose



  • Infusion:



  • 0.003–0.005 mg/kg/hr



  • Children >=50 kg



  • IV: 0.2–0.6 mg/dose


  • Onset: 5 min



  • Duration: 3–4 hr


  • Contraindicated in acute or severe asthma



  • Reverse with naloxone



  • Reduce dose when combined with benzodiazepines

Ketamine


  • IV: 0.5–2 mg/kg



  • IM: 2–5 mg/kg


  • IV:



  • Onset: 1 min



  • Duration: 5–10 min



  • IM:



  • Onset: 3–4 min



  • Duration: 15–30 min


  • Hallucinations may be blunted with benzodiazepine use



  • Hypersalivation (decreased by use with atropine 0.02 mg/kg)



  • Relatively contraindicated in conditions associated with elevated intracranial pressure (ICP)



  • Cautious use in hypertension

Morphine


  • IV: 0.05–0.2 mg/kg



  • Infusion:



  • 0.01–0.04 mg/kg/hr


  • Onset: 5 min



  • Duration: 3–5 hr


  • Life-threatening respiratory depression



  • Histamine release may result in hypotension



  • Contraindicated in acute/severe asthma if lack monitoring and resuscitation equipment, gastrointestinal (GI) obstruction



  • Reverse with naloxone



  • Reduce dose when combined with benzodiazepines

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Jan 14, 2019 | Posted by in PEDIATRICS | Comments Off on Sedation, Analgesia, Neuromuscular Blockade and Withdrawal

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