THE USE OF ANALGESICS, SEDATIVE MEDICATIONS PAIN, SEDATION IN CHILDREN

1. THE USE OF ANALGESICS, SEDATIVE MEDICATIONS PAIN, SEDATION IN CHILDREN Compiled by Tina M. Slusher, MD University of Minnesota Contributions from: JOHN BERKENBOSH, M.D. University of Louisville CHERI LANDERS, M.D. University of Kentucky LYNNE W. COULE, M.D. Medical College of Georgia DAVID ROSEN, M.D. West Virginia University STEVE BARNES, M.D. Rush University

2. Add oxycotin • Add rectal morphine • Scheduled versus prn

3. Conflict of Interest • I have nothing to disclose

4. Children especially neonates feel less pain than adults w/similar painful stimuli • True • False

5. Anesthesia Myths cont. • Wrong!! Children do feel pain and neonates likely feel even more pain • Pain transmission begins @2weeks gestation w/development of skin and mouth sensory neurons • Appearance of pain inhibitory apparatus begins at about 32 wks gestation

6. <20 years ago common belief was than infants did not feel pain and no anesthesia was used even during surgery • In 1992, a trial2 showed deep anesthesia during cardiac surgery↓ physiologic stress responses and mortality & gave convincing evidence of importance of adequate analgesia for newborn infants • Untreated pain may have undesirable long-term consequences, even after fairly minor procedures Nelson’s textbook

7. Analgesia/Sedation Myths Concerns about respiratory depression make pain control impossible in children Wrong again!!! • Need to titrate and Need to monitor • Easy to overshoot in < 6 months • Caveat in the < 6 month old infant • Opioids can cause apnea prior to pain relief • Neonates may not get good pain relief from morphine but is commonly used in neonates-more studies needed.

8. Concerns about addiction should limit appropriate pain control • True • False

9. Analgesia/Sedation Myths • True addiction rarely happens with appropriate pain control • “Addiction” • Addiction vs. Tolerance vs. Dependance

10. Addiction • A common fear voiced by health care workers • Includes a psychological “need” or craving along with physical withdrawal symptoms if medication is discontinued • People in real pain DON’T become addicted as long as medication titrated to pain

11. Tolerance • The same dose of medication no longer has the same effect as when first started • More commonly occurs in patients on long term continuous infusions of sedatives or analgesics rather than intermittent dosing especially if not titrated to the clinical situation • There are currently NO medications to which tolerance will not develop

12. Dependence • Removing medication results in withdrawal symptoms • To avoid withdrawal, may need to wean sedative or analgesic or change to long acting agents such as methadone or clonidine when patient has been on the medication for 1 week or more

13. ASSESSING PAIN • JCAHO – pain as 5th vital sign (mandate) • Developmental and cultural barriers • Ability to verbalize • Cultural attitudes to pain coping/treatment • Non-painful contributors to “pain-like” behaviors

14. Assessing Pain VAS-can be used in 8yo Faces scale  4yo

15. Assessing Pain cont. • Autonomic measures • Heart rate • Blood pressure • Behavioral or combined behavioral-physiologic scales (e.g. facial expression, limb movement ± heart rate & blood pressure

16. What is Analgesia? “Relief of the perception of pain without intentional production of a sedated state. Altered mental status may be a secondary effect of medications administered for this purpose.”

17. MANAGING PAIN • 1990 – WHO pain management ladder • Stepwise approach, based on anticipated severity • 1° developed for cancer pain, adapted for all acute pain • Outpatient and inpatient applications • Enteral and intravenous routes encouraged

18. WHO LADDER MILD PAIN: • NSAIDS, Acetaminophen ± adjuvants MODERATE PAIN: • NSAID or acetaminophen ± weak opioid (oxy, hydro, codeine) ± adjuvants • IV opioids with scheduled NSAID or acetamin • PCA vs CI vs intermittent • Regional Anesthetic techniques SEVERE PAIN: • IV opioids (PCA/CI) ± adjuvants • Regional Anesthetic techniques ± adjuvants

19. ANALGESIANSAIDS • Ibuprofen: • Onset – 60-90 min • Peak – 2-4 hrs • Duration – 6-8 hrs • 80% oral bioavailability • Hepatic metabolism via oxidation, excreted in urine

20. ANALGESIANSAIDS • Ketorolac • 0.5-1 mg/kg q6h, po/IV/IM • Onset – 10/30 min, peak – 40-60/90-180 min • Duration – ~6 hrs • Similar kinetics in infants, children, adolescents • Time limited regimen

21. ANALGESIANSAIDS • Ketorolac • 0.9 mg/kg equipotent to 0.1 mg/kg morphine • >5 y.o. • Munro (2002) – morphine PCA ± q6h ketorolac PSF • 0.2 mg/kg ketorolac • Sustained  morphine, diazepam requirements • Surgical concerns re impaired wound healing • Some of our orthopedic surgeons (KCH) DO NOT allow in in scoliosis surgery • Limited data in <6 mo

22. Morphine • Opioid • Advantages • Analgesia • Less expensive than fentanyl • Disadvantages • no amnesia, anxiolysis • Histamine release - wheezing, hypotension • Urinary retention • Longer onset than fentanyl

23. ANALGESIAMORPHINE • Dose/route • IV/IM - 0.05-0.1mg/kg/dose - onset 2-3 min, duration 3-4 hr • infusion 0.01-0.04 mg/kg/hr • po - 0.2-0.5 mg/kg - slow - onset 30-60 minutes • onset – <5 min/1 hr • Peak – 20 min/1-2 hr • Duration – 3-5 hr

24. ANALGESIAMORPHINE • More widely available than fentanyl • Advantages: -Cheap • Disadvantages: • pruritus, hypotension, bronchospasm, sedation, urinary retention

25. ANALGESIAFENTANYL • Synthetic opioid, ~ 100X more potent than morphine • More “hemodynamically friendly” than morphine • 100x more potent than morphine • shorter duration than morphine • onset in 2-3 min, lasts 30-60 min • less histamine release than morphine

26. Fentanyl • Disadvantages: • no amnesia • “Steel chest” or “rigid chest” phenomenon • more likely with large bolus dose • Treat with reversal of fentanyl or paralyzation or midazolam

27. Fentanyl cont. • Dose/route: • IV - sedation/analgesia - 1-3 mcg/kg/dose - anaesthesia - 5-10 mcg/kg/dose - infusion - 3-5 mcg/kg/hr • Oral - 5-10 mcg/kg

28. ANALGESIAFENTANYL • IV/transmucosal • onset – <2 min/5-15 min • Peak – <5 min/20 min • Duration – 30-60 min/1-2 hr • Transmucosal – 25% buccal (rapid), 75% GI (slow)

29. Tramadol • Non-opioid analgesia • Central inhibition of seroton and non-epinephrine • Causes some inhibition of ascending pain pathway • PO • Dose 1-2 mg/kg/dose q 4-6 hours (max 400mg/day)

30. Pethidine • Bad choice but sometimes only one available • Agonist-Antagonist • Metabolite can build up and cause respiratory depression w/out adequate pain control • Often underdosed • Dose 0.3-1mg/kg/dose q6hours

31. Ketamine • Low dose ketamine may be alternative for pain control • See latter section on ketamine for more information

32. Sucrose/Breastfeeding in Neonates • Sucrose with or without a pacifier can be used for both pain and stress control in the neonate • Breastfeeding + sucrose or glucose may be best alternative? • However, recent article in Lancet questions whether oral sucrose actually does reduce pain because although pain score was lower there was no difference in nociceptive or spinal withdrawal activity (Slater R et al, Lancet. 2010;376:1225-1232

33. ANALGESIANALAXONE (NARCAN) • Reverses sedation, analgesia, respiratory depression • NO agonist activity so NO risk sedation/respiratory depression with overdoses • Dose: 0.1 mg/kg IV/IM • use incremental doses (0.005-0.01 mg/kg) to avoid adverse • Adverse: • short half-life, resedation/depression • opioid withdrawal (infants of addicted mothers) • agitation, seizures, N+V

34. Pediatric Procedural Sedation Tina M. Slusher, MD Associate Professor of Pediatrics

35. WHY SEDATE?

36. SEDATIONRATIONALE • Anxiety • underlying illness • separation from parents • transport environment and transfers • Ability to perform procedure • Safety - risks of motion (invasive) • Motion interference (i.e. radiologic)

37. What Presedation Assessment Do You NEED?

38. PRESEDATION ASSESSMENTHISTORY • Brief and Targeted: • Procedure being done and why • Pertinent past history • underlying medical conditions • prior sedations/anaesthetics and reactions to them • Underlying airway issues • Present medications - consider possible interactions • Allergies - get specifics - not all reactions are allergies-include food allergies as well • Family history of anaesthetic reactions • NPO Status • Determine specific sources of anxiety

39. Patient’s NPO status • <6 mo 2 hours for clears and 4 hours for breast milk and 6 hours for formula or food • >6 mo 2 hours for clears and 6 hours for food unless diabetic or GER or other situations at increased risk for delayed emptying

40. PRESEDATION ASSESSMENTPHYSICAL EXAM • Complete vitals, including room air SaO2 • Airway - micrognathia/macroglossia, tonsils/adenoids • obesity (compliance) • Underlying lung disease - need to pretreat wheezing etc. • Evidence of hypovolemia • Neurologic status - relates to ability to protect airway • many of these patients are on other CNS-altering medications

41. Precautions Include • Airway • Critical Airway: trauma, anatomic abnormality, neonate, full stomach, loose tooth • Ventilation • Risk for hypoventilation neonate, debilitated, mentally compromised patient, hx of apnea

42. SEDATION EFFECTSCARDIOVASCULAR CONSIDERATIONS • Primary concern is hypotension • vasodilation (esp. venous) (most agents) • beware of patient with hypovolemia (presedation fasting) • drugs may be synergistic • myocardial suppression (barbiturates, propofol) • Precipitation of dysrhythmias • include contribution of relative bradycardia as some drugs (opioids) blunt the normal compensatory HR response to vasodilation/hypovolemia

43. Volume Depletion/Hypotension(Hemodynamic issues) • IF intravascularly volume depleted or hypotensive may have a  in BP if administered sedatives • IF intravascularly volume depleted or hypotensive should be appropriately fluid resuscitated & hemodynamically stable PRIOR to receiving sedation!

44. How do you determine the best agent? What questions do you ask? What do you need to know?

45. AGENT DETERMINATION • Relative need for anxiolysis vs analgesia • Depth of sedation desired/required • Duration of procedure • Degree of patient/family anxiety • prior experiences with procedures  sedation • Underlying medical conditions • include family history of reactions to anaesthetics • airway - obstruction, oral anatomy, CLDz • hemodynamic - volume status, cardiac function

46. Sedation and Pain Control are synonymous. • True • False

47. SEDATION DOES NOT EQUAL PAIN CONTROL Some drugs like barbiturates actually increase pain by inhibiting neural pathways 

48. SEDATIONDEFINTIONS Mild (Conscious) Sedation • minimally depressed level of consciousness • ability to independently maintain airway patency retained • respond appropriately to physical or verbal stimulation Deep (Unconscious) Sedation • controlled state of decreased or lost consciousness • risk of partial/complete loss of airway protection/patency • partial/complete inability to respond appropriately General Anaesthesia • medically controlled state of unconsciousness • complete loss of airway protection and responsiveness

49. Continuum of Consciousness General anesthesia Awake, baseline Conscious sedation Drowsy Deep sedation

50. ALL SEDATION CAN PROGRESS TODEEP SEDATION REGARDLESS OF THE DRUG OR DOSE EMPLOYED!