sedation - Pediatric Resident Curriculum for the PICU...

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Unformatted text preview: Pediatric Resident Curriculum for the PICU UTHSCSA SEDATION and ANALGESIA in the PICU Pediatric Resident Curriculum for the PICU UTHSCSA GOALS • Analgesia for painful diseases and procedures • Compliance with controlled ventilation and routine intensive care • Amnesia for the periods of sedation • Reduce the physiological responses to stress • Avoid complication Pediatric Resident Curriculum for the PICU UTHSCSA SEDATION and ANALGESIA • Inadequate analgesia and postsurgical stress response is a metabolic, humoral, and hemodynamic response following injury or surgery • This neuroendocrine cascade leads to increased oxygen consumption, increased carbon dioxide production, and a generalized catabolic state with a negative nitrogen balance Pediatric Resident Curriculum for the PICU UTHSCSA SEDATION/ANALGESIA Sedation (seda/shun) [L. sedatio, to calm, allay]. The act of calming, especially by the administration of a sedative, or the state of being calm. Analgesia (an­al­je/zi­ah) [G. insensibility, from an ­ privative,negative + algesis, sensation of pain] A condition in which nocioceptive stimuli are perceived but are not interpreted as pain; usually accompanied by sedation without loss of consciousness. Pediatric Resident Curriculum for the PICU UTHSCSA IDEAL PICU SEDATIVE/ANALGESIA • • • • • • • • • • Rapid onset Predictable duration No active metabolites Rapid recovery Multiple routes of delivery Easy to titrate Minimal cardiopulmonary effects Not altered by renal or hepatic disease No drug interactions Wide therapeutic index Pediatric Resident Curriculum for the PICU UTHSCSA COMMON DRUGS UTILIZED • • • • • • • • Opiates (Narcotics) Benzodiazepines Chloral hydrate Barbiturates Ketamine Propofol Neuroleptics Paralytics Pediatric Resident Curriculum for the PICU UTHSCSA SITUATIONS REQUIRING SEDATIVES/ANALGESIA • MECHANICAL VENTILATION – Respiratory failure – Airway – Neurological • POST OPERATIVE • HEAD INJURY • PULMONARY HYPERTENSION • PROCEDURES Pediatric Resident Curriculum for the PICU UTHSCSA OPIOIDS First line drugs Provide analgesia and sedation, NOT amnesia Act similarly as a class Produce delayed gastric emptying, decreased intestinal peristalsis, and urinary retention • Narcotic to be used: – Morphine – Fentanyl – Methadone • • • • Pediatric Resident Curriculum for the PICU UTHSCSA OPIOIDS ROUTE OF ADMINISTRATION – IV – Oral – Transmucosal – Transdermal MODE OF ADMINISTRATION – Intermittent/on demand (as necessary) – Fixed interval – Continuous infusion – PCA Pediatric Resident Curriculum for the PICU UTHSCSA MORPHINE • • • • • • • • Gold standard Hepatic metabolism Depresses respiration by altering chemoreceptor sensitivity to CO2 Depresses rate over tidal volume Decreases sigh frequency Can cause hypotension due to histamine mediated vasodilation Can block compensatory catecholamine effect Prolonged clearance in neonates Pediatric Resident Curriculum for the PICU UTHSCSA MORPHINE • PCA dosing • IV intermittent – 0.1 mg/kg q 3 ­ 4 hrs – Initial dosing: 50 mcg/kg q 10 minutes • IV continuous until comfortable – 0.05 mg ­ 0.1 – Demand dose: 20 ­ 40 mg/kg/hr mcg/kg • PO scheduled – Lock­out period: 10 minutes – 0.3 mg/kg q 3 ­ 4 hrs – 4­hour limit: 0.25 mg/kg Pediatric Resident Curriculum for the PICU UTHSCSA FENTANYL • Synthetic opiate, 100 x more potent than morphine • Rapid onset, highly lipophilic, rapidly crosses BBB, redistributed to fatty tissue • Short distribution t1/2, long elimination t1/2 • • • Minimal hemodynamic effect Bluntspulmonary vascular responses May produce “chest wall rigidity”, reversed with relaxants or naloxone Pediatric Resident Curriculum for the PICU UTHSCSA FENTANYL • IV intermittent dosing – 1­2 mcg/kg q 1­2 hrs • IV continuous dosing – 1­2 mcg/kg/hr • Transdermal delivery system available – Not recommended in children less than 12 yrs – 25,50,75,100 mcg/hr – 25 mcg/hr is equivalent to 15 mg morphine in a 24 hr period Pediatric Resident Curriculum for the PICU UTHSCSA METHADONE Equipotent to morphine Minimal hemodynamic effects Long half life Sedation and euphoric properties less pronounced than morphine • Useful for pain control and abstinence PO dosing – 0.1 mg/kg q 4­8 hrs – 50 % oral bioavailability – Drug accumulation with repeated doses caused by extensive protein binding • • • • Pediatric Resident Curriculum for the PICU UTHSCSA MODE OF ADMINISTRATION • Intravenous bolus administration – Common – PRN ­ as needed – Half­life of drug determines interval – Disadvantage of pain breakthrough Pediatric Resident Curriculum for the PICU UTHSCSA IV BOLUS ADMINISTRATION Pediatric Resident Curriculum for the PICU UTHSCSA CONTINUOUS INFUSION • Utilized when prolonged analgesia and sedation needed • Less labor intensive • Better analgesia, initial bolus important • Need for dedicated IV site Pediatric Resident Curriculum for the PICU UTHSCSA CONTINUOUS INFUSION Pediatric Resident Curriculum for the PICU UTHSCSA PCA • Patient controlled analgesia • Allows patient to administer a preset amount of narcotic at preselected intervals • Improved analgesia with decreased narcotic use • Option to include low basal rate • Nurse controlled analgesia – Eliminates delay – Allows delivery via a closed system Pediatric Resident Curriculum for the PICU UTHSCSA PCA Pediatric Resident Curriculum for the PICU UTHSCSA OPIATE SIDE EFFECTS • RESPIRATORY DEPRESSION – Reversal ­ Nalaxone (Narcan) • Full reversal 0.1 mg/kg • Partial reversal ­ titrate to effect • Half life is less than narcotics • IV,IM,Sub Q, ETT • Abrupt reversal may result in nausea, vomiting, sweating, tachycardia, increased BP, and tremors Pediatric Resident Curriculum for the PICU UTHSCSA OPIATE SIDE EFFECTS • Pruritis – Individual variability and susceptibility, alleviated by Benadryl • Tolerance – Need for increase in dose to achieve the same effect – Generally develops after 2­3 days of frequent/continuous use – Greater with fentanyl – Treated by increasing the dose as needed Pediatric Resident Curriculum for the PICU UTHSCSA OPIATE SIDE EFFECTS • DEPENDENCE – Physiological state leading to abstinence syndrome on withdrawal of the drug – Generally develops after 7­10 days of sustained use – Symptoms include: mydriasis, tachycardia, goose bumps, muscle jerks, vomiting, diarrhea, seizures, fever, hypertension – Treated with gradual withdrawal of the drug Pediatric Resident Curriculum for the PICU UTHSCSA OPIATE SIDE EFFECTS • DEPENDENCE – In general the longer the period of treatment the longer the period of withdrawal needed – A child is at risk for dependence if they have been on narcotics for a week – Finnegan scoring to monitor adequate weaning dose – Weaning strategies can vary, typically 10% decrease per day • Do not spread the dosing interval beyond the normal dosing interval, rather decrease the dose • Can substitute methadone and wean q 48 hrs over a longer time period Pediatric Resident Curriculum for the PICU UTHSCSA BENZODIAZEPINES • First line agents for sedation • Providehypnosis, anxiolysis, antegrade amnesia, and anticonvulsant activity • NO ANALGESIA • Can cause abstinence syndrome after prolonged use • Mechanism in the limbic system via the inhibitory neurotransmitter, gamma aminobutyric acid (GABA) Pediatric Resident Curriculum for the PICU UTHSCSA DIAZEPAM (VALIUM) Sedating, variable amnesia, anxiolytic Irritating to veins, pain in PIV Multiple active metabolites – Advantage for prolonged sedation – Disadvantage for rapid arousal – Not recommended for continuous infusion • Half­life 12­24 hrs • Hepatic metabolism • • • Pediatric Resident Curriculum for the PICU UTHSCSA LORAZEPAM (ATIVAN) • • • • Improved amnesia No active metabolites Half life 4­12 hours Metabolized by glucuronyl transferase – Less influence from other drugs – Better preserved in patients with liver disease Pediatric Resident Curriculum for the PICU UTHSCSA MIDAZOLAM (VERSED) Rapid onset • Other routes of administration Rapid metabolism – Oral Good amnesia – Nasal Water soluble, no pain with injection – Rectal • Half life 2 ­4 hours – Sublingual • Hepatic metabolism with • Less absorption renal excretion requiring increase dosing – Active hydroxy­ metabolite may accumulate • • • • Pediatric Resident Curriculum for the PICU UTHSCSA MIDAZOLAM • Reports of dystonia and choreoathetosis post infusion, greater risk in neonates • Heparin decreases protein binding, increases free drug • Disadvantage cost – 20 kg patient – 80 $/day compared to Ativan = 30 $/day Pediatric Resident Curriculum for the PICU UTHSCSA BENZODIAZEPINES SIDE EFFECTS • RESPIRATORY DEPRESSION – – – Less than narcotics, but potentiated with narcotics Dose related Reversal • Flumazenil ­ benzodiazepine receptor antagonist • Contraindicated in patients with chronic benzo use for seizures, mixed overdose, TCA’s ­ may result in seizures Pediatric Resident Curriculum for the PICU UTHSCSA BENZODIAZEPINES SIDE EFFECTS Choreoathetoid movement disorder Tolerance – As with narcotics may need to increase dose following 2­3 days use • Dependence – Withdrawal carefully and slowly if on greater than 7­10 days – Signs of withdrawal ­ tremor, tachycardia, hypertension, – Rapid withdrawal may promote seizures • • Pediatric Resident Curriculum for the PICU UTHSCSA CHLORAL HYDRATE • • • • • • • • Sedative hypnotic agent Metabolized in the liver to its active form, trichlorethanol Half life 8­12 hours Oral or rectal administration Onset of action delayed Paradoxical reaction in some older children Not to exceed 100 mg/kg/day ­ i.e.: 25mg/kg/q 6 hrs Caution in children < 3 months or with hepatic dysfunction Pediatric Resident Curriculum for the PICU UTHSCSA BARBITURATES Sedative Respiratory depression dose dependent Negative inotropic effects/vasodilation ­ decreased cardiac output • Decreased cerebral O2 consumption • • • – ↓CBF – ↓ ICP • Anticonvulsant Pediatric Resident Curriculum for the PICU UTHSCSA BARBITURATES • Useful in patients with increased ICP • Short acting barbiturate useful for sedation for procedure/imaging in hemodynamically stable child • Alkaline solution, often incompatible with TPN or meds. Pediatric Resident Curriculum for the PICU UTHSCSA MAJOR TRANQUILIZERS • Phenothiazine – Thorazine • Butyrophenones – Droperidol – Haloperidol • Common in adult ICU, uncommon in PICU • Side effects hypotension due to alpha blockade and extrapyramidal effects • At times useful in the difficult to sedate child Pediatric Resident Curriculum for the PICU UTHSCSA KETAMINE Dissociative IV anesthetic Good amnesia and somatic analgesia Anesthetic state classically described as a functional and electrophysiological dissociation between the thalamoneocortical and limbic system • Chemically related to phencyclidine and cyclohexamine • Water and lipid soluble • Quickly crosses blood­brain barrier, < 30 seconds • • • Pediatric Resident Curriculum for the PICU UTHSCSA KETAMINE • • • • • • • Redistribution half­life 4.7 minutes Elimination half­life 2.2 hours Clinical effects evident within one minute, resolution within 15 ­ 20 minutes of dose Bronchodilation Sialagogue ­“promoting the flow of saliva” – Administer with an anticholinergic • Atropine or Robinol Minimal net hemodynamic effect – Negative inotrope – Central effect ­ ↑HR, ↑SVR Good choice in shock or status asthmaticus Pediatric Resident Curriculum for the PICU UTHSCSA KETAMINE Risk of laryngospasm Risk of emesis/aspiration Increases ICP , globe pressure Seizure inducing Emergent reactions, hallucinations – Improved with administration of a benzodiazepine • IM: 2 ­ 4 mg/kg dose q 30 minutes ­ 1 hour • IV – Intermittent dosing • 1 ­2 mg/kg dose q 30 minutes to 1 hr – Continuous dosing • 1 ­ 3 mg/kg/hr • • • • • Pediatric Resident Curriculum for the PICU UTHSCSA PROPOFOL • Sedative/hypnotic – Dose dependent ­ conscious sedation to general anesthesia – Rapid onset (20­50 seconds) – Quick recovery ( within 30 minutes of d/c) – Lack of active metabolites – Metabolized in liver – Excreted in urine Pediatric Resident Curriculum for the PICU UTHSCSA PROPOFOL • Lipid emulsion, reports of anaphylaxis – Soybean oil, egg lecithin, and glycerol • Decreased ICP, may lower CPP • Decreased sympathetic tone – Contraindicated in hemodynamically unstable – Moderate respiratory depression • Pain with injection/infusion site – Improved with use of 1% lidocaine – 0.5 mg/kg Pediatric Resident Curriculum for the PICU UTHSCSA PROPOFOL • Neurologic sequela – Opisthotonic posturing – Myoclonic movements • Metabolic acidosis reported with use > 24 hrs • Contraindicated for long term use • Doses – 1 ­ 3 mg/kg induction – 20 ­ 100 mcg/kg/min – Increase infusion rate 5­10 mcg/kg/min increments of 5 ­ 10 minutes ...
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