Sedation and Analgesia

Assessment & Goals - Tiny Patient Comfort

• Rationale: Systematic assessment prevents adverse effects of pain/agitation & over-sedation.
• Primary Goals: Patient comfort, anxiolysis, amnesia; facilitate interventions, prevent self-harm.
• Challenges: Communication barriers, developmental variations in pain expression.
• Pain Scales (Age-Appropriate):
  • Neonates: NIPS (Neonatal Infant Pain Scale)
  • Infants/Non-verbal (<3 yrs): FLACC (Face, Legs, Activity, Cry, Consolability)
  • Verbal Children (3-7 yrs): Wong-Baker FACES Pain Rating Scale
  • Older Children (>8 yrs): Numeric Rating Scale (NRS)
• Sedation Scales:
  • COMFORT-B Scale (ventilated patients)
  • Richmond Agitation-Sedation Scale (RASS/pRASS)
  • State Behavioral Scale (SBS)
• Titration: Adjust therapy to achieve predefined sedation/analgesia targets; frequent reassessment vital.

⭐ FLACC scale (Face, Legs, Activity, Cry, Consolability) scores each category 0-2 (total score 0-10); widely used for non-verbal children.

Pediatric Analgesics - Pain Relief Parade

• Non-Opioids: First-line, mild-moderate pain.
  • Paracetamol (PCM):
    • Central COX inhibitor.
    • Dose: 10-15 mg/kg/dose PO/PR q4-6h; IV 15 mg/kg/dose q6h. Max 75 mg/kg/day.
    • SE: Hepatotoxicity (>150 mg/kg dose); Antidote: NAC.
  • NSAIDs (e.g., Ibuprofen):
    • Peripheral COX inhibitor.
    • Ibuprofen Dose: 5-10 mg/kg/dose PO q6-8h. Max 40 mg/kg/day.
    • SE: GI upset, renal impairment. Avoid <3-6 mo.
• Opioids: Moderate-severe pain.
  • Morphine:
    • Dose: IV 0.05-0.1 mg/kg/dose q2-4h.
    • SE: Resp. depression, hypotension, nausea.
  • Fentanyl:
    • Dose: IV 0.5-2 mcg/kg/dose q30-60min. Rapid onset.
    • SE: Chest wall rigidity, resp. depression.

    ⭐ Fentanyl is preferred over morphine in hemodynamically unstable patients due to less histamine release and better cardiovascular stability.

  • Tramadol:
    • Dose: 1-2 mg/kg/dose PO/IV q4-6h.
    • SE: Nausea, seizures (high dose).
• Opioid Reversal: Naloxone 0.1 mg/kg (max 2mg/dose).

Pediatric Sedatives - Calm & Composed

• Benzodiazepines (BZDs): GABA-A agonists. Anxiolysis, amnesia.
  • Midazolam: Short. IV 0.05-0.1 mg/kg.
  • Lorazepam: Intermediate. IV 0.05-0.1 mg/kg.
  • Reversal: Flumazenil (⚠️ seizure risk).
• Alpha-2 Agonists: Central α2. Sedation, anxiolysis, mild analgesia. Min. resp. depression.
  • Dexmedetomidine: IV Load 0.5-1 mcg/kg; Maint 0.2-1.5 mcg/kg/hr.
    • 📌 DEX-MED: Calm, Slow HR, Easy Breath.
    • SE: Bradycardia, hypotension.

⭐ Dexmedetomidine: sedation without significant respiratory depression, aids ventilator weaning.

• Propofol: GABA-A. Rapid on/off.
  • IV: Induct 1-3 mg/kg; Maint 25-100 mcg/kg/min.
  • ⚠️ PRIS: >4 mg/kg/hr >48h (acidosis, rhabdo).
• Ketamine: NMDA antagonist. Dissociative sedation, analgesia.
  • IV 1-2 mg/kg. Airway reflexes preserved. Bronchodilation.
  • SE: Emergence reactions, ↑secretions.
• Barbiturates (Phenobarbital): GABA-A. Deep sedation, anticonvulsant.
  • SE: Resp. depression, hypotension.

Protocols & Problems - Navigating Nuances

• Procedural Sedation (PSA):
  • Goal: Safe analgesia & anxiolysis.
  • Key: Pre-sedation assessment. 📌 Mnemonic: SOAP ME (Suction, Oxygen, Airway, Pharmacy, Monitors, Equipment).
  • Monitor: SpO₂, HR, RR; capnography.
  • ⚠️ Reversals (Naloxone, Flumazenil) ready.

• Sedation in Mechanical Ventilation (MV):
  • Target: RASS -2 to 0 or SBS -1 to +1.
  • Strategy: Analgesia-first (opioids), then sedatives (benzos, dexmedetomidine). Daily Sedation Interruption (DSI).
• Complications:
  • Withdrawal: WAT-1 score > 4. Gradual taper.
  • Delirium: Assess with CAPD/pCAM-ICU. Non-pharmacological first.
  • Tolerance: ↑ dose for effect. Consider opioid rotation.

⭐ Dexmedetomidine provides sedation without significant respiratory depression, useful for weaning.

High‑Yield Points - ⚡ Biggest Takeaways

• Pain assessment is crucial; use age-appropriate scales (FLACC, NIPS, Wong-Baker).
• Prioritize non-pharmacological methods (sucrose, swaddling) for minor procedural pain.
• Midazolam: common anxiolytic/sedative; monitor for respiratory depression.
• Ketamine: provides analgesia/sedation, preserves airway reflexes; risk of emergence reactions.
• Fentanyl: potent opioid analgesic; risk of chest wall rigidity, apnea.
• Propofol: rapid onset/offset; monitor for hypotension, Propofol Infusion Syndrome (PRIS).
• Always ensure continuous vital signs monitoring during pediatric sedation.