Pediatric Sedation and Analgesia

Key Concepts

Patients of all ages experience pain, including infants, neonates, and premature babies.
Oligoanalgesia, the inadequate treatment of pain, has many short-term and long-term consequences: worse patient outcomes, increase in patient’s pain threshold, and development of chronic pain.
Pain management may include a combination of techniques: analgesics, topical anesthetics, local anesthetic injections, oral sucrose in infants, and nonpharmacologic interventions.
Nonpharmacologic interventions to decrease pain or anxiety include parental presence; physical measures, such as heat or cold therapy and splinting for musculoskeletal injuries; and behavioral or cognitive measures, such as distraction and play therapy.
Topical anesthetics are recommended to decrease the pain of minor procedures, such as venipuncture or IV cannulation.
Techniques for decreasing the pain of intradermal injections include topical agent prior to the intradermal injection; slowly injecting warmed, buffered local anesthetic solution from within the wound with the smallest gauge needle possible; and limiting the number of needle punctures.
When using large amounts of local anesthetics in small children or infants, calculate the drug dose to avoid toxicity; a 1% solution = 1 g/100 mL or 10 mg/mL.
Procedural sedation and analgesia (PSA) requires pre-sedation evaluation; sufficient monitoring (during and after the procedure) by qualified individuals capable of dealing with any adverse events that may occur; age-appropriate equipment (including airway equipment) and medications (including reversal agents and advance life support drugs); and discharge criteria for when the patient is fully awake, returns to baseline with normal vital signs, and is able to be discharged in the care of a responsible adult.
Overall, preprocedural fasting is not necessary for most emergency patients, because large studies show no clinically significant differences with airway complications, emesis, or other adverse effects between groups of patients stratified by their preprocedural fasting status.
Choice of sedative and analgesic for PSA depends on many variables including patient factors and the procedure to be done. Slow titration of medications can achieve the desired level of sedation and analgesia while minimizing risk of adverse events.

Sedation

Foundations

Sedation is a controlled reduction of environmental awareness. Sedation is a continuum that begins with minimal, moving to moderate, then deep sedation, and may proceed to general anesthesia.

Definitions ^,

Anxiolysis is a state of decreased apprehension concerning a particular situation in which the patient’s level of awareness does not change.
Analgesia refers to the relief of pain without the intentional alteration of mental status, such as occurs in sedation. An altered mental state may be a secondary effect of the medications administered for this purpose.
Minimal sedation (e.g., anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive functions and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
Moderate sedation/analgesia (formerly called “conscious sedation”) refers to a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from the painful stimulus is NOT considered a purposeful response. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Dissociative sedation is a trancelike cataleptic state induced by the dissociative agent ketamine and characterized by profound analgesia and amnesia, while protective airway reflexes, spontaneous respirations, and cardiopulmonary stability are maintained.
Deep sedation/analgesia describes a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even with painful stimulation. The ability to independently maintain ventilatory function is usually impaired. Patients require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.
Procedural sedation and analgesia (PSA) are techniques of administering a sedative or dissociative agent, usually along with an analgesic, to induce a state that allows the patient to tolerate painful or unpleasant procedures while maintaining adequate spontaneous cardiorespiratory function. It is intended to result in a depressed level of consciousness that allows the patient to maintain oxygenation and airway control independently and continuously.

The goal of PSA is to alleviate the anxiety, pain, and suffering associated with medical procedures. PSA is an essential part of emergency medicine practice and part of the core curriculum for emergency medicine training programs. Providers should be prepared to appropriately manage the airway and in rare instances intubate if sedation becomes deeper than expected.

Specific Issues

Preparation

The patient’s American Society of Anesthesiology (ASA) physical status classification should be calculated prior to procedure ( Table 157.1 ) and airway assessed, for example, using the Mallampati score (see Chapter 1 ) to identify potential difficulties. Children with special needs, anatomic airway abnormalities, moderate to severe tonsillar hypertrophy, and current or recent upper respiratory illness present increased risk and require additional consideration. ^, ASA classes I and II are considered appropriate candidates for minimal, moderate, or deep sedation. Staff are encouraged to consult with appropriate subspecialists (e.g., pediatric anesthesiologist) if there is a question of sedation adverse events because of an underlying medical/surgical condition (e.g. Pierre Robin syndrome). Those aged less than 3 months or with weight less than 5 kg are at increased risk for sedation adverse events.

TABLE 157.1

American Society of Anesthesiologists Physical Status Classification

Class	Description	Examples	Sedation Risk
I	Normal and healthy patient	No past medical history	Minimal
II	Mild systemic disease without functional limitations	Mild asthma, controlled diabetes	Low
III	Severe systemic disease with functional limitations	Pneumonia, poorly controlled diabetes mellitus, hypertension or seizure disorder	Intermediate
IV	Severe systemic disease that is a constant threat to life	Advanced cardiac disease, renal failure, sepsis	High
V	Moribund patient who may not survive without procedure	Septic shock, severe trauma	Extremely high
VI	A declared brain-dead patient whose organs are being removed for donor purposes

There should be at least one provider, in addition to the provider performing the procedure, who is responsible to monitor appropriate physiologic parameters and assist in any needed supportive or resuscitation measures. Pulse oximetry and capnography readings should be continuously monitored; depth of sedation, heart rate, blood pressure, and respiratory rate should be recorded at regular intervals. Although there are scales for assessing the depth of sedation in pediatric patients, continuous monitoring is more important than any specific measurement on a sedation scale. Although there is no evidence of benefit in young healthy individuals, cardiac monitoring has been shown useful in those with a cardiac history and older patients. Thus, we recommend continuous cardiac rhythm monitoring, especially for high-risk patients (e.g., preexisting cardiovascular disease or a history of dysrhythmias) or high-risk procedures (e.g., cardioversion).

Providers administering pediatric procedural sedation should have training and skills in airway management and be ready to rescue the patient from a deeper level than intended for the procedure, since it is common for children to pass easily into a deeper level of sedation. In addition to monitoring equipment and oxygen, age-appropriate suction, bag-valve-mask, and intubating equipment should be available and readied prior to administering medications. The SOAP-ME mnemonic provides an equipment checklist for sedation :

S ize-appropriate suction catheters (connected, checked, and with suction turned on)
O xygen supply (connected to bag and turned on)
A irway: Size-appropriate airway equipment (appropriate size mask and intubation supplies)
P harmacy: Advanced life support medications and antagonists
M onitors: Size-appropriate oximeter, end-tidal carbon dioxide monitor, and blood pressure cuff
E quipment or drugs for a particular case

Children over age 4 can benefit from simple information about what to expect for their procedure. Explaining the steps, as well as what they might see or feel, being shown the medical supplies (e.g., irrigation solution), and offering realistic options for their procedure help them feel in control. Similarly, parents should be prepared for where to sit and how they can assist with positioning or distraction. A child’s ability to control behavior and cooperate for a procedure depends on chronologic age and cognitive/emotional development.

Preprocedural Fasting

The ASA has guidelines for preoperative fasting in healthy patients of all ages undergoing elective procedures. In patients undergoing PSA in the emergency department (ED), the evidence indicates that preprocedural fasting does not decrease the risk of emesis or aspiration, as noted in the American College of Emergency Physicians (ACEP) clinical policy. ^, Recent studies in pediatric patients do not find any evidence of association between vomiting and shortened fasting time, and no patients were found to have aspiration. Therefore, adherence to the ASA preoperative fasting guidelines for procedures is not necessary in ED patients undergoing PSA.

Supplemental Oxygen and Capnography During Procedural Sedation and Analgesia

Use of supplemental oxygenation has been shown to decrease the incidence of desaturation in pediatric patients from 17% to 10%, although it may delay the recognition of hypoventilation or apnea. Oxygen desaturation and delay in assisted ventilation events can be significantly reduced with the use capnography. Close capnography monitoring can detect hypoventilation early, prior to a drop in pulse oximetry, irrespective of use of supplemental oxygen. ACEP and AAP clinical policy recommend capnography be routinely used to monitor ventilation in children undergoing PSA.

Specific Medications

Table 157.2 details specific PSA sedative agents commonly used in infants and children. Patient age, preexisting conditions, and anticipated level of pain or anxiety should guide choice of sedative. Providers should administer drugs by slow intravenous (IV) titration to decrease the risk of adverse events, including hypotension and respiratory depression. For intranasal medications or nitrous oxide use, employing a Child Life specialist or the parents to assist with distraction, music, or other cognitive behavioral modalities may be advantageous.

TABLE 157.2

Commonly Used Sedatives for Procedural Sedation in Children and Infants

Sedative ^a	Route	Dose ^b	Usual Dose ^c	Maximum Dose	Onset	Duration	Side Effects	Advantages/Comments ^a
Dexmedetomidine	IN	2–4 mcg/kg/dose	3 mcg/kg/dose	200 mcg (100 mcg/nare)	30 min	60–90 min	Decreased HR and BP	Contraindication with heart block, severe renal or hepatic impairment or use of beta blockers
Etomidate	IV	0.1–0.3 mg/kg	0.2 mg/kg PSA	0.4 mg/kg	<1 min	3–10 min	Pain on injection, myoclonic movements, adrenal insufficiency (prolonged use)	Minimal CV/respiratory depression
Ketamine ^d	IV	1–2 mg/kg initial (repeat 0.5–1 mg/kg for longer procedures)	1.5 mg/kg initial PSA		1 min	15 min	Sympathomimetic effects (↑HR, ↑BP) Nausea, vomiting Emergence reaction Laryngospasm (rare)	Warn parents of nystagmus as an expected effect. Has analgesic effect CV/respiratory stability bronchodilator (use in asthmatics) Battlefield use/disasters
Ketamine	IM	4 mg/kg	4 mg/kg 2 mg/kg if <2 years old		5 min	30 min	(Same as above) Higher risk of nausea	(Same as above)
Ketamine	IN	3–9 mg/kg			10 min	60 min	(Same as above)	(Same as above)
Midazolam ^e	IV	0.05–0.1 mg/kg (6 months to 5 years old or adult) 0.025–0.05 mg/kg (≥6 years old) Give slowly 1–2 mg over ≥ 2 min and titrate to effect	If giving with fentanyl, may dose at 0.02 mg/kg	0.6 mg or 6 mg if ≤5 years old and 10 mg if >6 years old	5 min	30 min	Paradoxical agitation, vomiting, coughing, hiccups, dizziness, respiratory depression, apnea so use lower dose if given with opioids or respiratory depressants	Protective in seizure patients ↓ ICP, CBF, ↓ LV filling pressure may benefit cardiac patients Mild CV effects unless hypovolemicReversed by antagonist flumazenil
Midazolam	IN	0.2–0.5 mg/kg	0.2 mg/kg	10 mg	<10 min		(Same as above)	(Same as above)
Pentobarbital ^f	IV	1–6 mg/kg	1–2 mg/kg initial, repeat 3–5 min to desired effect or max dose	100 mg/dose	1–2 min	15–60 min	CV/respiratory depression, paradoxical agitation, extravasation can cause tissue necrosis Contraindication: Porphyria	↓ IOP, ↓ ICP , used to treat status epilepticus Use in head injury/neurology patients Can use if malignant hyperthermia
Propofol	IV	0.5–1.5 mg/kg (repeat 0.5 mg/kg every 3–5 min for longer procedures)	Variable, may be 1 mg/kg	None	<1 min	5–15 min (mean 8 min)	CV/respiratory depression Use with caution if shock/low BP/impaired cardiac function Caution if allergy to eggs, soybean oil, EDTA ^g	Rapid onset/recovery No dose change if renal or liver disease Can use if malignant hyperthermia
Nitrous oxide	Inhalation	Dose is 30%–70% mixture	Commercially available in 50%:50% mixture	70%	1–2 min	15–20 min	Contraindications: Trapped air (bowel obstruction, pneumothorax, emphysema, air emboli)	Need a scavenger system and proper ventilation, potential for abuse, chronic exposure may have adverse effects

fPentobarbital can be given PO or PR or IM, but onset and duration are longer with more variable effect, so IV is preferred.

^g Although the manufacturer’s labeling lists egg allergy as a contraindication, available studies (mostly retrospective) and an American Academy of Allergy, Asthma, and Immunology statement have suggested that propofol may be used safely in soy- or egg-allergic patients (AAAAI [Lieberman 2015]; AAAAI 2019; Asserhoj 2016; Dziedzic 2016; Murphy 2011). In patients with more severe soy or egg allergy, some experts recommend the use of an alternative anesthetic or a small trial dose of propofol prior to full dose administration (Sicherer 2020).

BP, Blood pressure; CBF, cerebral blood flow; CV, cardiovascular; EDTA, ethylenediaminetetraacetic acid; HR, heart rate; ICP, intracerebral pressure; IM, intramuscular; IN, intranasal; IOP, intraocular pressure; IV, intravenous; LV, left ventricular; PO, per oz. (by mouth); PR, per rectum; PSA, procedural sedation and analgesia; RSI, rapid sequence intubation.

a Other agents used for sedation, e.g., DPT (meperidine [Demerol], promethazine [Phenergan], and chlorpromazine [Thorazine]) IM should be avoided because there are better, newer agents for sedation with fewer side effects. Chloral hydrate has been used in the past but is used infrequently at present because there are other better options.

b Doses will vary with the individual patient; these are some generally recommended starting doses. Some patients will need greater than the typical maximum dose, whereas others may be sedated with less than the usual dose. It is best to titrate the dose in all patients.

c Be especially cautious in at-risk patients. At-risk patients include those patients with significant heart disease, including heart failure or pulmonary hypertension, liver disease, renal failure, and patients at the extremes of age (infants, particularly neonates and the geriatric patient). It may be prudent in these patients, to “start low and go slow.”

d Ketamine’s effect on ICP is discussed in the text. Previously ketamine was thought to be contraindicated if there was an increase in ICP. However, recently, this concept has been challenged. If ketamine is given PO or PR, higher doses are needed with less predictable effect and increased side effects so PO and PR routes are not recommended.

e Midazolam may be given by several routes including IV, IM, IN, PO, and PR. The PO and especially PR routes of administration have more variable absorption and effects, so they are not commonly used.

Propofol

Propofol has several advantages for PSA; it has a rapid onset in 30-60 seconds, is short acting, and has antiemetic properties. Its side effects include hypotension and respiratory depression. However, studies have shown safe administration in the ED for sedation by physicians who are skilled in airway management and resuscitation of patients that may enter deeper sedation or respiratory distress. Although the dosing of propofol varies from 0.5 to 2 mg/kg, an initial dose of 0.5 to 1.0 mg/kg should be administered and titrated to effect with additional doses, usually in increments of 0.5 mg/kg.

Ketamine

Ketamine, a dissociative anesthetic, has sedative, amnestic, and analgesic properties. Ketamine maintains cardiovascular and respiratory stability, has minimal respiratory depression, and maintains protective airway reflexes in patients with spontaneous respirations. Ketamine’s sympathomimetic effects include increased blood pressure, heart rate, cardiac output, and bronchodilation, making it the preferred sedative in patients with asthma.

Apnea is rare with ketamine (0.8% incidence), but has been associated with very high doses, rapid administration, and co-administration with narcotics or other respiratory depressants. Ketamine increases salivary secretions, which may increase the incidence of laryngospasm, especially in oral procedures; however laryngospasm can typically be resolved with simple airway maneuvers. Laryngospasm is usually transient and responds to repositioning of the head, supplemental oxygen administration, gentle suctioning if secretions are the irritant, and positive pressure ventilation with a bag-valve mask. Although rarely needed, the use of a paralytic at lower doses than required for intubation (e.g., succinylcholine given at 10% of a paralytic dose) has been shown to break laryngospasm when the above measures fail. Rapid sequence intubation is rarely needed, but a last resort option to treat laryngospasm.

Ketamine may be given intravenously, intramuscularly, per os (by mouth; PO), or intranasal (IN). For IV administration in pediatric patients, initial doses range from 1.0 to 2.0 mg/kg, with further bolus doses of 0.5 to 1 mg/kg titrated to desired effect. Intramuscular (IM) dosing is an option when IV access is unobtainable; dosing ranges from 4 to 5 mg/kg. The disadvantages of IM ketamine include a higher rate of vomiting, longer recovery time, and lack of IV access in the event of complications requiring IV medication administration (e.g., paralytics). IN ketamine can be used in dosing ranges from 3-9 mg/kg/dose with onset of action between 5 and 10 minutes. As with all intranasal medications, the optimal intranasal dose per nare is 0.5 to 1 mL.

Use of Ketamine in Patients With Head Injury

Multiple studies have dispelled the myth that ketamine increases intracranial pressure (ICP). Ketamine may even have beneficial effects on the brain, including protection against seizures, cerebral ischemia, and secondary brain injury related to hypotension.

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