Sedation and Analgesia for the Pediatric Patient

imagesTo provide anxiolysis, analgesia, sedation, and motor control during unpleasant diagnostic or therapeutic procedures. Decisions regarding appropriate sedation practices depend on:


   imagesType of procedure or treatment


   imagesAge and medical condition of the patient


   imagesSkill and experience of practitioner


   imagesAvailable staff


   imagesPolicies and procedures of the institution


CONTRAINDICATIONS



imagesNo absolute contraindications to analgesia other than significant allergies


   imagesPain control is an essential component of good emergency care


   imagesChoice of agent depends on level of pain, speed of action, medical condition, and age of patient


imagesRelative Contraindications


   imagesPresence of acute or chronic conditions which make the patient American Society of Anesthesiologists (ASA) class III or higher (anesthesiology should be involved in the care of these patients; general anesthesia in the operating room [OR] may be indicated)


   imagesInadequate personnel available


      imagesExcept for mild anxiolysis (oral benzodiazepines) or analgesia without sedation, person administering sedation cannot be the same person performing the procedure


      imagesThe Centers for Medicare and Medicaid Services (CMS) recommends two physicians (one to manage sedation, one to perform procedure) and a nurse be present for the duration of the sedation. The American College of Emergency Physicians (ACEP) Clinical Policy on Procedural Sedation and Analgesia in the Emergency Department recommends one physician (performing the procedure) and one nurse be present for the sedation.


RISK/CONSENT ISSUES



imagesInadvertent deep sedation or general anesthesia


imagesHypoxia/hypoventilation


imagesNausea and vomiting


imagesMedication reactions


   imagesFentanyl: Respiratory depression, rigid chest (more likely with rapid delivery)


   imagesMorphine: Histamine release and hypotension


   imagesBenzodiazepines, barbiturates: Paradoxical reaction of restlessness or agitation


   imagesKetamine: Laryngospasm, emergence reactions, and hypertension


   imagesPropofol: Hypotension


CLASSIFICATION



imagesOften, moderate sedation is the goal for emergency department procedural sedation; however, the depth of sedation should be determined by the procedure being performed and the patient characteristics. One must be aware of the possibility of the patient passing into a state of deep sedation and be able to manage this occurrence. Advanced airway management skills are required for anyone performing procedural sedation.


   imagesMinimal/mild sedation: Impaired cognitive function and coordination but unaffected ventilatory and cardiovascular functions; able to respond to verbal commands


   imagesModerate sedation: Blunted anxiety/pain responses but intact airway reflex; normal cardiovascular function; patient should respond to verbal commands (possibly with addition of light tactile stimulation).


   imagesDissociative sedation: Profound analgesia and amnesia with retention of airway reflexes, spontaneous respirations, and cardiovascular function


      imagesState induced by ketamine


   imagesDeep sedation: Difficult to arouse; can respond purposefully to repeated or painful stimulation; partial or complete loss of airway reflexes is possible; cardiovascular function usually intact


PRESEDATION CONSIDERATIONS



All patients should have a presedation assessment, which includes the following:


imagesConsider type and severity of underlying medical conditions; consult anesthesiology for patients of ASA class III and higher (TABLE 90.1)


imagesConsider current medications and allergies especially regarding previous adverse experiences with analgesia/anesthesia


imagesInspect airway for abnormalities or limited neck mobility that may impair rescue airway intervention (short neck, obesity, large tonsils/tongue, small mandible)


imagesDetermine time and nature of last meal: Fasting recommendations for elective procedures are 2 to 3 hours for liquids and 4 to 8 hours for solids; in an emergency situation, these guidelines are often not realistic; document the time of last intake and the need for emergent treatment.


imagesPerform a general physical examination, concentrating on cardiac and lung auscultation, presence of active upper respiratory infection (URI) or asthma exacerbation, and baseline neurologic state


imagesAssemble all equipment you may need for sedation and potential complications:


   imagesSuction


   imagesOxygen delivery system (face mask or nasal cannula of appropriate size)


   imagesAirway equipment


   imagesMonitors (pulse oximeter, electrocardiography, blood pressure, capnography)


   imagesMedications, including reversal agents



imagesGeneral Basic Steps


   imagesPresedation evaluation


   imagesChoosing appropriate agent


   imagesInduction of sedation


   imagesMonitoring


   imagesRecovery

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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Sedation and Analgesia for the Pediatric Patient

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