SEDASI DAN ANALGESIA ANAK SAKIT KRITIS

Dadang Hudaya SomasetiaUKK Gawat Darurat Pediatri, IDAI

Palembang 2014

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DISCLOSURE

Dr Dadang Hudaya Somasetia certify that there is no conflict of interest in relation to this presentation.

Palembang 2014

Sedasi dan Analgesia Anak Sakit Kritis

TUJUAN PEMBELAJARAN

1. Mengenal obat serta metode sedasi dan analgesia pada anak sakit kritis

2. Memahami cara melakukan sedasi dan analgesia pada anak sakit kritis

3. Menguasai teknik sedasi dan analgesia pada anak sakit kritis

Palembang 2014

Sedasi dan Analgesia Anak Sakit Kritis

PENDAHULUAN

• Luaran fisiologis, neurologis & psikologis • Sedatif mengurangi rasa cemas & gelisah• Analgesia mengatasi rasa nyeri • Kombinasi sedatif dan analgesia

Sedasi dan Analgesia Anak Sakit Kritis

Sedasi dan analgesia tidak adekuat: Respons stres metabolik, humoral, hemodinamis

Kaskade neuroendokrin konsumsi O2 ↑, produksi CO2 ↑, katabolisme, balans nitrogen (–)

Sedasi dan Analgesia Anak Sakit Kritis

BatasanSedasi Tindakan untuk menenangkan, terutama dengan pemberian sedatif, atau upaya yang menenangkan Sensasi nyeri/rangsang hebat (-)

Rasa takut dan kecemasan (-) Potensiasi dg analgesia, ingatan traumatis (-)

Analgesia Kondisi stimuli nosiseptif terasa tetapi tidak diinterpretasikan sebagai nyeri Biasanya diberikan bersama-sama dengan sedasi tanpa kehilangan kesadaran

Obat Sedatif dan Analgesik Ideal

• Onset cepat

• Durasi dapat diprediksi

• Tidak menghasilkan metabolit aktif

• Pulih cepat

• Rute masuk obat multipel

• Mudah dititrasi

• Efek kardiopulmonum minimal

• Tidak dipengaruhi oleh penyakit ginjal dan hati

• Tidak ada interaksi dengan obat lain

• Indikasi terapi luas

Pemakaian Sedasi - Analgesia

• Ventilasi Mekanis• Pascaoperasi• Cedera kepala (head injury)• Hipertensi pulmonum • Berbagai prosedur klinis

• Hilang rasa nyeri,

takut dan cemas

• Amnesia

• Kooperatif

• Kenyamanan

• Keamanan

Pertimbangan memilih obat: IndikasiDurasi yang diharapkanFarmakodinamikIndikasi kontra

Tingkatan Sedasi

Sedasi Minimal (Ansiolisis)Masih berespons normal terhadap perintah verbal. Kognitif dan koordinasi baik

Tidak memengaruhi sal. napas, ventilasi, kardiovaskuler

Sedasi Menengah (Sedasi Sadar [Conscious Sedation])Masih merespons perintah verbal atau rangsang taktil minimal

Tidak perlu intervensi sal. napas dan pernapasan, kardiovaskuler dipertahankan

Sedasi DisosiatifKataleptis ~ kondisi ‘trans’ yg diinduksi ketamin, analgesia dalam dan amnesia,

Retensi refleks protektif sal. napas, napas spontan & fungsi kardiopulmonum

Sedasi DalamDepresi, sulit dibangunkan, respons rangsang nyeri (+)

perlu alat bantu patensi ventilasi & kardiovaskuler

Anestesia UmumHilang kesadaran, tidak dapat dibangunkan. Ventilasi spontan terganggu

alat bantu patensi sal. napas & fungsi kardiovaskuler, VTP

Sedatif-Analgesik yang Sering Dipakai

Tabel 1. Berbagai Sistem Skoring Sedasi

Subjective Observer RatingVisual analog scalesStewardRamsayHarrisModified Glasgow Coma ScaleObserver’s Assessment of alerness/Sedation Scale (OAA/S)CambridgeBloomsburyCook/NewcastleNeurobehavioral Assessment Scale (NAS)Sedation-Agitation Scale (SAS)

Patient Task PerformanceDigital symbol substitution test (DSST)Choice reaction time (CRT)Memory testsVisual analog scales

Physiologic Measures IncludedCOMFORTNisbet and NorrisHeart rate variabilityEsophageal sphincter contractilityPRST (Pressure, rate, sweat, tearing)

Sedasi dan Analgesia

Tabel 2. Skala Ramsay untuk Penilaian Sedasi

Tingkat Deskripsi Sedasi Skala Ramsay

1234 5 6 

Sadar, cemas; gelisah atau tidur gelisah, atau keduanyaSadar, kooperatif, terorientasi, dan tenangRespons hanya terhadap perintah verbalMengantuk, respons cepat thd ketukan ringan glabela atau rangsang suara kerasMengantuk, respons lambat thd ketukan ringan glabela atau rangsang suara kerasMengantuk, tidak ada respons thd ketukan ringan glabela atau rangsang suara keras

Sedatif-Analgesik yang Sering Dipakai

AlertnessDeeply asleepLightly asleepMengantukFully awake and alertHyperalertCalmness/agitationCalmSlightly anxiousAnxiousVery anxiousPanickyHeart rateDenyut jantung (HR) < baselineDenyut jantung sesuai baselineHR jarang >15% diatas baseline (1−3 selama periode observasi)HR sering >15% diatas baseline (>3 selama periode observasi)HR terus menerus sekitar >15%)Facial TensionOtot fasial relaksasi totalTonus otot fasial normal, tidak ada tegangan otot fasial yang jelasTegangan jelas pd beberapa otot fasialTegangan jelas pada seluruh otot fasialOtot fasial mengerut dan meringis

 12345 12345 123 4 5 12

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Mean arterial blood pressure (MAP)Tekanan darah MAP di bawah baselineTekanan darah MAP pada baselineMAP jarang >15% di atas baselineMAPsering >15% di atas baseline (>3 selama periode observasi)MAP terus menerus >15% diatas baselineRespons respirasiTidak ada batuk dan napas spontanNapas spontan, sedikit atau tidak ada respons

ventilasiSesekali batuk atau resistensi ventilatorBernapas aktif terhadap ventilatorBatuk atau selalu melawan ventilator, batuk atau tersedakTonus ototRelaksasi otot total, tidak ada tonus ototPenurunan tonus ototTonus otot normalTonus otot meningkat, fleksi jari tangan& kakiRigiditas otot ekstrimPhysical movementTidak ada pergerakanSesekali dan sedikit pergerakanSering, sedikit pergerakanPergerakan kuat pada ekstremitasPergerakan kuat termasuk torso dan kepala

 1234 5 12 345  12345 12345

 

Tabel 3. Skala COMFORT untuk Menilai Sedasi

The COMFORT SCALE, 6 behavioral and 2 physiologic measures. The nurse observes the patient for 2 minutes during which the patient is scored on alertness, degree of calmness or agitation, respiratory response, physical movement and facial tension. The administrator observes the heart rate and mean arterial blood pressure every 15-20 seconds and determines whether these are within 15 % of the baseline.Total scores can range between 8 and 40. A score of 17-26 generally indicates adequate sedation and pain control.

The FLACC (Faces, Legs, Activity, Cry and Consolability) pain assessment tool to recognize pain and make the right analgesic choice. The use of this tool is appropriate in

preverbal children in pain from surgery, trauma, cancer or other disease processes. Behavioral assessment tool for scoring postoperative pain in non-verbal patientsThis scale may also be helpful in the aphasic patient

Indicators are divided in 5 categories : facial expression, movement (of legs), activity, cry and consolability. Each item is scored from 0 - 2. The total score is between 0 and 10. A score between 1 and 3 = no or mild pain, between 4 and 6 = moderate pain. A score of 7 or higher = serious pain.

Children with Cognitive Impairment

• Often unable to describe pain• Altered nervous system and experience

pain differently

• Use behavioral observation scales – e.g. FLACC

• Can apply to intubated patients

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Minimal

• General Description “Anxiolysis”

• Responsiveness

• Airway

• Ventilation

• Cardiovascular

“Appropriate”

UnaffectedUnaffectedUnaffected

SEDATION LEVELS

Riskof

AdverseEvent

NoSedation

MildSedation

Greg Hollman, MD, FAAPMedical Director, Pediatric Sedation ProgramUniversity of Wisconsin Children’s HospitalMadison, Wisconsin

Timothy E. Corden, MD, FAAPAssociate Professor of PediatricsAssociate Director, Pediatric Critical Care MedicineMedical College of WisconsinMilwaukee, Wisconsin

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Minimal Moderate

• General Description “Anxiolysis” “Conscious”

• Responsiveness

• Airway

• Ventilation

• Cardiovascular

“Appropriate”

UnaffectedUnaffectedUnaffected

“Purposeful” to light stimulation

No interventionAdequate

Maintained

SEDATION LEVELS

Riskof

AdverseEvent

NoSedation

MildSedation

ModerateSedation

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Minimal Moderate Deep

• General Description “Anxiolysis” “Conscious” “Deep sleep”

• Responsiveness

• Airway

• Ventilation

• Cardiovascular

“Appropriate”

UnaffectedUnaffectedUnaffected

“Purposeful” to light stimulation

No interventionAdequate

Maintained

“Purposeful” to pain stimulation

(±) Intervention

(±) Inadequate

(±) Maintained

SEDATION LEVELS

Riskof

AdverseEvent

NoSedation

MildSedation

ModerateSedation

DeepSedation

ContinuumDrug Induced - Level of Sedation

American Society of Anesthesiologists (ASA)

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Choosing a Moderate Sedation Plan

Remember mnemonic AMPLE!!• A llergies• M edications• P ast Medical History• L ast Meal• E vents leading to sedation

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Equipment & SuppliesAAP recommends S O A P M E

Suction – age/size-suction catheters and apparatus (Yankauer-type)

Oxygen – adequate O2 supply, working flow/delivery devices

Airway – age/size-appropriate airway equipment (e.g., ET tubes, LMAs, oral and nasal airways, laryngoscope blades, stylets, bag mask)

Pharmacy – life-saving drugs, reversal agents (Naloxone, Flumazenil)

Monitors – pulse oximeter, BP, ECG, cardiac, EtCO2

Equipment – special equipment/drugs (e.g., crash cart w/ defibrillator, respiratory box, IV access equipment) (Pediatric 2006;118:2587-2605)

MOST IMPORTANT WELL TRAINED PERSONNEL IN ADVANCED LIFE SUPPORT!

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Pre-Sedation Risk AssessmentAmerican Society of Anesthesiologists (ASA Class) 1941

Physical Status Classification I A healthy patient

II A patient with systemic disease, with no functional limitations

III A patient with severe systemic disease which limits activity but is not incapacitating

*IV A patient with an incapacitating disease that is a constant threat to life

*V A patient not expected to survive 24 hours with or without an operation

* It is recommended that the patients receive sedation by appropriately trained anesthesiologists and intensivists

PFCCS 2008

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PharyngealSegment

NasalSegment

TrachealSegment

THE UPPER AIRWAYPharyngeal collapse

during sedation

inhibition

IX X

P(-)P(O)

Greg Hollman, MD, FAAPMedical Director, Pediatric Sedation ProgramUniversity of Wisconsin Children’s HospitalMadison, Wisconsin

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Physical ExamMallampati - The Difficult Airway

• Mallampati/Samsoon Classification– Class I: soft palate, uvula, pillars – Class II: soft palate, portion of uvula – Class III: soft palate, base of uvula – Class IV: hard palate only can be seen

• Other predictors of difficult airway– Obesity with short neck– Reduced neck movement– Inability to protrude the lower teeth – Reduced mouth opening– Receding mandible– Thyromental distance of less than 3 fingers

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ASA NPO Guidelinesfor gastric emptying

• Clear liquids − 2 hours• Breast milk − 4 hours• Infant formula − 6 hours• Non-human-milk − 6 hours• Light meal − 6 hours

These guidelines apply to all ages

These do not guarantee complete gastric emptying

Meals that contain fried or fatty foods and meat may prolong gastric emptying

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Mod-Sed Scale/Scoring Tool

Modified Ramsay Scale Provides a consistent method to

document the child’s level of sedation during and after a procedure

Modified Aldrete Score

When a child can be safely discharged after undergoing sedation/analgesia?

Indication Score*

1. Anxious, Agitated, Restless 1

2. Awake, cooperative, oriented, tranquil Accepts mechanical ventilation

2

3. Semi asleep but responds to commands

3

4. Brisk response to light glabellar tap or loud noise

4

5. Sluggish response to light glabellar tap or loud noise

5

6. No Response 6

*Desired score depends on indication for sedation

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Score of NINE (9) is required for DISCHARGE

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The Right Drug for the Right Pts

• There is no ideal drug or magic bullet…all drugs have potential complications

• Drugs to consider should fit your goals for sedation with minimum risk to the patient

Considerations when choosing a drug– Route of administration– Onset of action– Duration of action – Contraindications– Therapeutic advantages

All sedative drugs suppress the CNS

27Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006. 2006;367:766–80.

DRUG USED FOR MODERATE SEDATION

First Generation ChloralhydrateDiazepamMorphine and MeperidinePentobarbitalTiopental and Methohexital

Second GenerationMidazolamFentanylKetamineNitrous Oxide

Third Generation EtomidatePropofol

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The Favorite MOD-SED Drugs• Anesthetics:

– Propofol, Ketamine, (Pentobarbital)

• Analgesics:– Fentanyl, Morphine, Paracetamol, Ibuprofen, Ketorolac, NO

• Anxiolytics:– Midazolam, (Lorazepam), Diazepam

• Others:– Dexmedetomidine, Etomidate, Clonidine– Chloral Hydrate– Nitrous Oxide– Local anesthetics: Lidocaine, TAC, LET, EMLA

A new mixture of ketamine and propofol (KETOFOL), have also been reported. (Orlewicz MS et al. Procedural Sedation. MEDSCAPE  Updated: May 28, 2013)

SKALA PENILAIAN NYERI FLACC – Preverbal children

Kategori Skor0 1 2

Face Tak ada ekspresi tertentu atau senyum

Terkadang menyeringai atau menerutkan dahi, tidak tampak tertarik dengan sekitarnya

Sering megernyitkan dahi, menggerakkan dagu, gerakan menggigit

Legs Posisi normal atau relaksasi

Gelisah, tidak tenang, tegang

Menendang-nendangkan tungkai

Activity Tidur tenang, posisi normal, mudah bergerak

Menggeliat-geliat, tegang

Melengkung, kaku, atau menyentak-nyentak

Cry Tidak menangis (terbangun/tertidur)

Menguap atau merengek, kadang mengeluh

Menangis terus, menjerit / merintih, sering mengeluh

Consolability

Santai Perhatian mudah teralih, tenang bila disentuh,/dipeluk/ diajak bicara/main

Sulit untuk menenangkan diri

The Visual Analogue Scales (VAS). The most widely used non-verbal self report scales- measure subjective complaints of pain. Although scientific research proved this type of scales to be a reliable assessment tool, many in the medical profession question the VAS scale because of its lack of reproducibility. Self-report scale for pain/mood.

Can be used in large populations (adults and children > 3 years)Very easy and fast to use. Non-verbal. No specific training required

The visual analogue scale (VAS) unmarked line with extremes of pain where patients are asked to mark the point in the line that describes their pain.

The Numerical rating scale is similar to the VAS but uses numbers that indicate the severity of the pain.

How severe is your pain today ?

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What happen between the late famous Jacko with Propofol?Propofol infusion syndrome: a simple name for a complex syndrome. Propofol, a short-acting, intravenously administered sedative agent is what might have caused the cardiac arrest of the King of Pop, Michael Jackson.

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Propofol• Pure sedative, no analgesic or amnestic properties• Quick onset: 30 sec – 1 min• Short duration: 3-10 min, t1/2 30-90 minutes• Dose: 0.5 -1 mg/kg IV bolus over 2 min,

Continuous infusion: 50-150 mcg/kg/min• Bolus followed by cont. infusion or repeated boluses• Disadvantages: respiratory depression, hypotension,

bradycardia, metab. acidosis with prolonged infusion• Induction agent for GA, used for MRI’s, moderate

(procedural) sedation and for prolong sedation in ICU• Not recommended for PICU sedation• “Propofol infusion syndrome” can cause CV collapse

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Ketamine• Dissociative agent, produces a state of catalepsy• Translike sedation, analgesia and amnesia• Administered IV, IM, PO• Onset: 30 sec - 1 min (IV), 3-4 min (IM)• Duration: 5-10 min (IV), 15-30 min (IM)• Dose: 0.5-1 mg/kg (IV), 4-5 mg/kg (IM)

– Infusion: 5-20 mcg/kg/min

• Good safety profile, preserves airway protective reflexes, minimal effects on respiratory drive

• Good agent for asthma, potent bronchodilator

• Disadvantages: excess secretions, increased ICP, sensitizes laryngeal reflexes, emergence reaction

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Ketamine

• Anticholinergic added to reduce secretions– Atropine 0.01- 0.02mg/kg (min 0.1 mg, max 0.5 mg)

• Midazolam 0.05-0.1mg/kg added to reduce potential for emergence phenomenon

• Ketamine, atropine and midazolam (KAM) can be given as single IM injection to avoid multiple sticks

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Barbiturates

• Sedative hypnotic, no analgesic properties

• Highly lipid soluble • Administered w/ multiple routes (IV, IM, PO,

PR)• Function at GABA receptor complex• Not reversible

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PentobarbitalIV route• Onset: 3-5 min (IV) • Duration: 15-45 min (IV)• Dose: 1-2 mg/kg (up to 2-5 mg/kg, max 100 mg)IM route: 20-30 minutes prior to study

• Onset 10-20 minutes • Duration 1-2 hours• Dose: 2-6 mg/kg to maximum 100 mg

Disadvantages: NO reversal agent, no analgesia

(enhances pain perception)

Can produce sedative effects for up to 24 hours• Ensure fully awake prior to discharge

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Analgesics

Nitrous oxide (NO)• Inhaled analgesic• Rapid onset and offset• Requires special equipment • Requires cooperative patient• Does not work well for reduction of

acute, sharp pain (fracture reduction)

Non-narcotic Acetaminophen PO, PR, IV Ibuprofen PO Ketoralac PO, IM, IV No difference in effectiveness

between ibuprofen and ketoralac

Narcotics Morphine IM, IV Demerol IM, IV Fentanyl IV, PO Codeine and analogs PO Morphine and demerol may

cause nausea, vomiting, and histamine release

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Opiates• Most commonly used• Analgesia and sedation• No anxiolysis or amnesia• Natural derivatives of opium

– Morphine (gold standard) and codeine

• Semi synthetic compounds– Oxycodone and hydrocodone

• Synthetic compounds– Demerol, fentanyl and sufentanil

• Reversal agent – Naloxone• Hypotension, respiratory and CNS depression• histamine release

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Morphine Multiple routes (IV, IM, SQ)

Onset: 5-10 min (IV)

Duration: 4-6 hours

Dosage: 0.05-0.1mg/kg IV, IM, SQ

Administer every 5-10 minutes in increments to achieve desired level.

IV peak effect 15-30 minutes,

IM peak 30-60 minutes

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Fentanyl

• Short painful procedures• Rapid onset: 2-3 min (<30 sec IV)• Short duration: 30-60 min• Dose: 1-5 mcg/kg IV (order in micrograms not g)• Synthetic opioid,100x more potent than morphine• Reversal agent: Naloxone• Lack of histamine release• Disadvantages: no amnesia/ anxiolysis,

tight chest syndrome - “steel chest” (when high dose 15 mcg/kg, rapid administration)

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BenzodiazepinesTherapeutic Effects

• Sedative hypnotic agents• Anmestic, anxiolytic• No analgesic properties• Skeletal muscle relaxant• Potentiate GABA neuroinhibition• High safety profile• Reversible with Flumazenil

Adverse Effects• Respiratory depression• CNS depression• Potentiates hypotension

in volume-depleted pts• Tolerance and

withdrawal effects

Drug * Dose (IV) Onset Peak Duration

Midazolam 0.1 – 0.2 mg/kg <60 s 3-5 min 30-60 min

Lorazepam 0.05-0.1 mg/kg 2-3 min 26-30 min 2-6 h

Diazepam 0.1-0.2 mg/kg <10 s 1-2 min 30-90 min

*sedative-hypnotic doseRodrigo. PFCCS 1998

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Midazolam• Multiple routes, IV, IM, oral, nasal, rectal• Onset: 2-5 min (may <60 sec) IV• Duration: 30-60 min IV• IV dose:

6 mos-5 yrs: 0.05-0.2 mg/kg, max 0.6 mg/kg IV

>5 yrs: 0.025-0.05 mg/kg, max 0.4 mg/kg IV

• Oral dose is 0.5-0.75 mg/kg to max dose 20 mg

• Intranasal dose is 0.2-0.5mg/kg• Reversal agent: Flumazenil• Retrograde amnesia• Disadvantages: NO analgesia, paradoxical reactions

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Diazepam

• Onset: <10 sec (IV), 1-1.5 hours (oral)• Duration: variable but LONG 30-90 min

(oral)• Dose: 0.1-0.2 mg/kg (IV)

0.1-0.8 mg/kg/day (oral)• Useful for tapering• Disadvantages: accumulation, long half-

life, avoid rapid IV push

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Lorazepam

• Onset:2-3 min (IV)• Duration: 2-6 hrs (up to 12 hrs)• Dose: 0.05-0.1 mg/kg• Medium acting benzo• Disadvantages: mixed with propylene

glycol– Anion gap metabolic acidosis, osmolar gap– Avoid infusions

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Clonidine

• Centrally acting alpha-2 agonist• Onset: 30-60 min (oral)• Duration: 6-10 hours• Dose: 0.05 mg/day (oral)• Can convert to transdermal patch• Eases withdrawal & decreases anesthetic

requirements

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Dexmedetomidine

• Alpha-2 agonist– 1700x more selective for alpha 2

(compared to clonidine)

• Onset: 15-30 min• Duration: 60-120 min• Dose: load with 0.5-1 mcg/kg

– Infusion of 0.3 – 1.5 mcg/kg/hr

• Disadvantages: bradycardia, only approved for 24 hrs infusions

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Etomidate

• Ultra short acting agent– IV onset 1 minute,

– Duration 10-15 minutes

– Dose 0.3 mg/kg IV– Minimal cardiovascular effects– Reduces intracranial pressure– Can interfere adrenocortical function– Uncommon in pediatric sedations– Drug of choice for rapid sequence intubation in

hemodynamically unstable with increased ICP

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Chloral Hydrate

1. Pure sedative hypnotic with no analgesic properties

2. Used primarily for outpatient radiologic proc.s and EEG’s.

3. Administered PO/PR, dose range from 50-100 mg/kg not to exceed 2 grams. May be repeated in 30 minutes within dose ranges.

4. Long onset of action (40 minutes) and duration (1-2 hours)

5. Low success rate when age >2 years (>3 yrs)

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Most Useful Drug for Pediatric Emergencies

• Ketamin: Sedative analgesic of choice for intubating with hemodynamic instability of any etiology and those with severe bronchospasm

• Fentanyl: Analgesic of choice in the presence hemodynamic instability and severe bronchospasm

• Midazolam: adjunct to above in a small titrated dose but doesn’t have any analgesic effect

Continuous infusions for prolonged sedation:- Midazolam at 0,1 mg/kg/h/ IV- Fentanyl at 1-2 mcg/kg/h IV- Dexmedetomidine at 0.3-0.7 mcg/kg/h IV

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Emergency Intubation “Cocktail”KAM - VR

• Ketamine 1-2 mg/kg IV• Atropine 0.02 mg/kg up to 1 mg IV/IM/IO• Midazolam 0.025 to 0.05 mg/kg IV• Rocuronium 1 mg or Vecuronium 0,2

mg/kg IV- If not IV/IO can use IM succinylcholine

unless contraindicated by history- Anecdotal reports of effective use of IM

non depolarizing agent

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Neuromuscular Blocking Agents

• Never give neuromuscular blockade to patient you cannot bag-mask ventilate

• Never use neuromuscular blockade alone since these agents do not provide sedation, amnesia, or analgesia

Non depolarizing Agent

Dose (iv) Onset Duration

Rocuronium 0.6-1.2 mg/kg 30-60 s 30-40 min

Vecuronium 0.1-0.2 mg/kg 1-3 min 30-40 min

Pancuronium 0.05-0.1 mg/kg 1-3 min 40-60 min

Depolarizing Agent Dose IV Onset Duration

Succinylcholine 1.0-1.5 mg/kg (2 mg/kg for infants)

30-40 s 3-5 min

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Adjuncts to Sedation

Prepare for Unexpected Emergencies• Oxygen, bag and mask, and suction (SOAPME)• Use volume or fluid resuscitation• Have advanced airway equipment, intubation, medications,

and appropriate staff to monitor the patient

Establish rapport with child and parents, if applicableCalm environmentImageryPreemptive analgesiaLocal anesthetics

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Antagonists Naloxone Opiate antagonist

Flumazenil Benzo. antagonist

NaloxonePure antagonist, reverses sedative and analgesic properties of narcotics.

Will not reverse hypotension.

Short t1/2 (1-2 hours) result in repeated doses with longer acting narcotics.

DoseChildren <5 years and < 20 kg:

0.1 mg/kg IV, IM, SQ, ETT

Children > 5years or > 20 kg: 2 mg

May repeat Q 2-3 min - desired affect

1/10 of standard dose to reverse respiratory but not analgesic effects

FlumazenilVery short duration of action need repeated doses

Dose 0.02 mg/kg IV

May repeat every min. to achieve max dose of 1 mg

Can precipitate seizures in chronic benzodiazepine use and TCA overdose

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Therapeutic Advantages

• Not all side effects are harmful• Considerations for choice of drug

– Ketamine bronchodilator– Pentobarbital or Midazolam anti-convulsant– Diazepam muscle relaxation

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Contraindications

• All drugs should be used judiciously!!!• Commonly seen relative contraindications and

adverse effects

– Ketamine increased ICP, excess salivation, emergence reaction

– Propofol hypotension, acidosis– Dexmedetomidine bradycardia, arrhythmia– Benzodiazepine hypotension

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Sedation-AnalgesiaNon-pharmacologic Strategies

• Parental presence during procedure• Distraction, • Parent rub adjacent area to decrease local pain• Externally oriented play• Guided imagery• Sucrose 24%• Pacifier

?

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Safe Mod-SedPrepare for Unexpected Emergencies

• Optimize your patient prior to sedation– Correct acidosis– Keep euvolemic– Know your pts “AMPLE”

• Anticipate difficulties and be prepared (SOAPME)– Bag, mask, oxygen, +/- airway app. box– Suction app.– Normal saline/Lactated Ringer’s

• Monitors: O2, CO2, CR monitor, and BP• Appropriate staff to monitor the patient

Mod-Sed Documentation

Before Sedation:

• Presedation health

• (Aldrete score)

• Confirm staff privileges &

universal procedures

(i.e., “time out”)

• Drug calculations (include

reversal agents and local

anesthetics)

• Informed consent

• Instructions to family

During Sedation:• Drug name(s) &calculations• Route• Site• Time• Dosage (titrated to desired effect)

During administration:• FiO2 & duration of

sedating/analgesic agents• Level of consciousness• Heart rate, respiratory rate, SpO2

• Adverse events and corrective intervention/treatment given

Document at least once every 5 minutes until child reaches predetermined discharge criteria 58

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Goals of Moderate Sedation“Hipocrates Oath - Primum nonnocere”

(Do no harm)

• To relieve the anxiety and pain • To choose sedatives and analgesics that fits

the procedures with lightest degree of sedation

• Attempt non-pharmacologic approach • Qualified personnel and correct equipment • Monitor the patient condition until fully awake

in baseline state for a safe discharge • Patient’s safety and welfare

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Mod-Sed Discharge Criteria

• Airway, vital signs, and pulse oximetry have

returned to baseline• Patient follows commands (age-appropriate)• Patient is hydrated and tolerates oral fluids• Patient is arousable and has baseline level

of verbal ability• Patient can sit unaided (age appropriate)

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ModSedQuality Improvement (QI) indicators

SpO2 ≤ 90% requiring O2

Any complications; need for emergency interventionsAspiration; airway obstructionInability to complete the procedure as plannedLong recovery time; unplanned admissionHypotensionUse of reversal agentsProper documentation Death

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Take Home Message

• Many situations require sedation, its component including anesthesia, analgesia, anxiolysis, & amnesia

• There are several levels of sedation• Remember mnemonic “AMPLE” for sedation• Choosing the right drug(s) for the right patients• Always anticipate possible complications & be prepared • Sedation may be indicated for the benefit of the child, the

family, and the caregivers but must be done with careful consideration of the risks.

INDONESIAN PEDIATRIC ASSOCIATION DEDICATED TO ALL INDONESIAN CHILDREN

THROUGH MODERATE SEDATION

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Patient evaluation

Rescue SkillsMonitoring

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THANK YOU FOR

YOUR ATTENTION

DEDICATED TO THE HEALTH OF ALL INDONESIAN CHILDREN

IDAI

Palembang 2014