Pediatric Sedation and Analgesia Pediatric Nursing

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Pediatric Sedation and Analgesia Pediatric Nursing Powered By Docstoc
					Pediatric Sedation and Analgesia

                      Jan Bazner-Chandler
                      RN,MSN, CNS, CPNP
   Procedural sedation and analgesia (PSA) refers to the
    pharmacologic techniques of minimizing or eliminating a
    child‘s pain and anxiety related to invasive or potentially
    frightening treatments & procedures.
Historical Perspective
   AAP (American Academy of Pediatrics) seminal article
    1992 referred to as ―conscious sedation‖, & established
    guidelines for monitoring these patients.
   Defined as ―a depressed state of consciousness where the
    patient retains protective reflexes and responds
    appropriately to stimuli‖.
   AHCPR (Agency for Health Care Policy & Research)
    published federal guidelines for management of acute pain
    in adults & children.
Procedural Sedation Re-defined
 American College of Emergency Physicians re-named
  ―conscious sedation‖ as ―moderate sedation‖
Procedural sedation‘s goal was to medicate patients safely
  until they can tolerate unpleasant procedures; i.e, they
  aren‘t really ―conscious‖.
AHCPR Guidelines
1.   Provide adequate           3.Combine
     preparation of children     pharmacological & non-
     & families for procedure    pharmacological options
2.   Be attentive to             when possible (relaxation
     environmental comfort       & imagery/VR)
     (allow parents to stay,    4. If procedures will be
     quiet room, sign on         repeated, provide max
     door)                       S&A for 1st procedure
Four Levels of Sedation
The Joint commission and the American Society of
 Anesthesiologists (ASA) described the 4 levels of
     Anxiolysis
     Moderate Sedation
     Deep Sedation
     General Anesthesia
Minimal Sedation
   Anxiolysis or minimal sedation refers to a drug-induced
    state in which cognitive and motor function may be
    impaired. This state does not fall under the sedation
    monitoring strict guidelines.
Moderate Sedation
   Moderate sedation is a state of sedation in which a child
    responds purposefully to verbal commands with or
    without light tactile stimulation, and maintains protective
Deep Sedation
   Deep sedation and analgesia is a drug induced depressed
    level of consciousness in which patients respond
    purposefully only to repeated or painful stimulation, and
    may be accompanied by the loss of protective reflexes.
General Anesthesia
   General anesthesia refers to the drug induced loss of
    consciousness in which there is no response to painful
    stimulus, and loss of protective reflexes.
requires the patient to be very still for the
duration of the procedure, which may be
frightening for the child)
   MRI
   CT scan
   Echo-cardiogram (rarely)
   Radiation therapy
Sedation/Analgesia for Painful Procedures
   Lumbar puncture
   Bone marrow aspiration / biopsy
   Renal biopsy
   Chest tube insertion/removal
   Central line insertion/removal
   Peritoneal tap
Sedation for Emergency Procedures
   Incision and drainage
   Fracture reduction / splinting
   Repair of lacerations
Goals of Sedation
   Mood alteration in order to allay the patient‘s fear
    and anxiety
   Maintenance of consciousness and cooperation for
    those patients who must be awake enough to
    cooperate throughout the procedure
   Elevate the pain threshold with minimal changes in
    vital signs, protective reflexes and physiologic
   Complete the procedure safely in minimum time
Sedation and Analgesia Goals

    Achieve adequate sedation with minimal risk, minimal
    Minimize discomfort and pain
    Minimize negative psychological response by providing
     anxiolysis, analgesia, and amnesia
       Monitoring and Assessment
       Key Elements
   Pre-procedural criteria
   Management during sedation (intra-procedural)
   Post-procedure sedation assessment
   Release from observation/dismissal/discharge criteria
   Patient/child education and discharge instructions
   ASA patient classification/Modified Aldretti Score
   Pre-procedural criteria
   Feeding guidelines
   Procedure / Site verification and time out (Universal
ASA Classifications

• ASA Class
   • I: A normal healthy child
   • II: A child with mild systemic disease
   • III: A child with severe systemic disease
   • IV: A child with severe systemic disease that is
       a constant threat to life
   • V: A moribund child who is not expected to
        survive without the procedure
Pre-procedural Criteria
   History and Physical/allergies/sedation hx
   Informed consent..for procedure and sedation/analgesia
   NPO status
   Base-line vital signs
   Height and weight
   Adequate staffing
   Emergency equipment
Health Assessment
   Height / weight in kilograms
   Vital signs including blood pressure
   NPO status
   Allergies
   Current Medications (which may affect sedation level)
   Systemic diseases or genetic conditions
   Ability to intubated in the event of an emergency: size of
    jaw and ability to open mouth
   History of heart murmur or asthma
Informed Consent
   a consent will need to be signed by a parent or legal
    guardian for the procedure & medications, & should be
    accompanied by a note in the medical record.
   What constitutes an ‗informed consent?‖
 NPO Guidelines

   Age         Duration of fasting      Duration of fasting
              (milk, formula, solids)     (clear liquids)
  Infants     6 hours for formula fed        2 hours
    who               infants
  receive      4 hours for breast fed
formula or            infants
breast milk
Children>3           8 hours                 2 hours
NPO Guidelines
   Breast fed infants should be fasted for the normal interval
    between feeding
   When proper fasting has not been assured or in the case of a
    true emergency, ―the increased risks of sedation must be
    weighted against its benefits; and the lightest effective sedation
    should be used. In an emergency situation the child may
    require protection of the airway (intubation) before sedation‖,
    and emptying the stomach as much as possible.
TJC (The Joint Commission) Standards
   Procedure /Site Verification
   Marking the operative site
   Time out before procedure (Universal Protocol)
   All must be documented in the MR
BRN Scope of Practice
   Nurse Practice Act
   It is within the scope of practice of registered nurses to
    administer medications for the purpose of induction of
    conscious (procedural) sedation for short-term
    therapeutic, diagnostic or surgical procedures.
RN Responsibilities / Medications
   The knowledge base includes but is not limited to:
       Effects of medication/appropriateness of order
       Onset, peak, duration/reversal meds
       Potential side effects of the medication
       Contraindications for the administration of the medication
       Amount of medication to be administered/safe & therapeutic
RN Responsibilities / Safety
   Nursing assessment of the patient to determine that
    administration of the drug is in the patient‘s best interest.
   Safety measures are in force:
    ◦   Back-up personnel skilled and trained in airway management,
        resuscitation, and emergency intubation. One must be PALS
    ◦   Patient should never be left un-attended
    ◦   Registered nursing functions may not be assigned to
        unlicensed assistive personnel.
    ◦   RN must have no other duties other than to administer meds
        & monitor the patient
RN Safety Concerns
   Continuous monitoring of oxygen saturation
   Cardiac rate and rhythm
   Blood pressure
   Respiratory rate
   Level of consciousness/response to interventions
   Immediate availability of an emergency cart which
    contains resuscitative and antagonist medications, airway
    and PP ventilatory equipment (bag & appropriate size
    mask, defibrillator, suction equipment, means to
    administer 100% oxygen).
Institution Responsibilities
   The institution should have in place a process for
    evaluating and documenting the RN‘s training &
    competency for the management of clients receiving
    procedural sedation.
   Evaluation and documentation should occur on a periodic
Management During Procedure
   Patient monitoring
   Reportable conditions
   Side effects of sedation
   Benefits of sedation
   Medications
       Monitoring During Moderate

   Heart rate, blood pressure, breathing, oxygen level and
    alertness are monitored throughout and after the procedure
Reportable Conditions

   Oxygen saturation less than 90% or 3% decrease from baseline
   Change in vital signs of 20% or more
   Respiratory depression or distress
   Cardiac dysrhythmias
   Deep sedation or loss of consciousness
   Inadequate sedation and/or analgesic effect
   Interventions and patient response
   Failure to return to baseline status (within 2 points of Pre-
    Aldretti score within one hour)
Nursing Management
   Personnel
   Equipment
   Medications
   Medication reversal agents
   Management parameters
   Complications
Equipment/Supplies Needed for Sedation

   Pulse oximeter                Ambu bag & mask
   Cardiac monitor (if CV        Suction (device and
    disease or arrhythmias         Yaunker catheter)
    detected or anticipated)      O2 tubing & mask
   Blood pressure cuff           Patent IV site
   Crash cart in vicinity        Reversal agents ** at
   Defibrillator                  bedside
   Suction                       Oral/nasal airway and ET
   Emergency drugs and            tube of appropriate size
    resuscitation equipment
Medications used for Sedation and
Midazolam (Versed)

    Classification: Benzodiazepine
    Potent sedative, anxiolytic and amnestic with no analgesic
     effects. Potent respiratory depressant.
    Action: fast acting, short-acting CNS depressant.
    Desired sedation can be achieved in 3 to 6 minutes
    Indication and uses: to produce sedation, relieve anxiety, and
     impair memory of peri-procedural events.
    Suited for procedures that are not especially painful: central
     catheter placement (with analgesia), voiding cysto-
     urethrogram (VCUG), CT scan, MRI
Versed Dosing
   Midazolam can be given orally, intravenously, intra-nasally
    or rectally
       Dosing:
           Neonate dose: IV 0.05-0.2 mg/kg
           Children dose: Oral: 0.2-.04 mg/kg (max dose 15 mg) IM: 0.08mg/kg
            IV: 0.003-0.05 mg/kg (max dose 2.5 mg)
Chloral hydrate
   Classification: Sedative/Hypnotic, Non-barbiturate, no
    analgesic properties
   Action:
   Dosing
       Neonate: Oral: 30-75 mg/kg/dose
        Maintenance dose: 20-40 mg/kg/dose
       Children: Oral 25-100 mg/kg/dose (max dose of 1 gm for
        infants & 2 gm for children)

       Onset: 30 minutes to one hour
       Duration: 4 to 8 hours
Morphine Sulfate
   Classification: Narcotic analgesic
   Action: opium-derivative, narcotic analgesic, which is a
    descending CNS depressant. Immediate pain relief with IV
    administration, peak analgesia at about 20 minutes, lasts
    up 2 to 4 hours.
Morphine Surlfate
 Morphine dosing
      Neonate : IV 0.05 mg/kg **Neonates may require higher dose range-
       (0.1 mg/kg)
      Children: Oral: 0.1-0.3mg/kg
                   IV: 0.03-0.05 mg/kg (max dose 10 mg/dose)
      Adolescents: Oral 5-8mg/dose
                       IV: 3-4 mg/dose
Meperidine (Demerol)not used much in peds

   Classification: Narcotic Analgesic
   Action: Synthetic narcotic analgesic and CNS depressant,
    similar but slightly less potent than Morphine
   Dosing
       Neonate: IV 0.5 mg/kg/dose
       Child: oral / SC / IM 1-2 mg/kg/dose (max 100 mg/dose)
       Child IV: 0.5 – 1 mg/kg/dose (max 100 mg/dose)
   Classification: potent opioid analgesic/respiratory
    depressant; fast and short-acting
   Useful for short painful procedures such as bone marrow
    aspiration, chest tube placement and fracture reduction.
   Dosing for patients over 2 years of age
       1 to 3 mcg/kg/dose over 3 to 5 minutes
       May be repeated in 30 to 60 minutes
Ketamine/only used under
anesthesiologist’s supervision
   Classification: general anesthetic producing both analgesia
    and sedation while maintaining airway tone.
   Action: blocks association pathways, inducing a dreamlike
    state of mind before producing a sensory blockage.
   Uses: especially useful for short, painful procedure.
   Dosing
       Neonate: 0.5mg-mg/kg
       Children: Oral 6-10mg/kg in liquid—poor absorption when
        given orally
                   IV: 0.5 mg-mg/kg
                   IM: 3-7 mg/kg
Reversal Agents
 Benzodizepine antagonist antidote: (Romazicon/flumazinil)
 Naloxone Hydrochloride narcotic antagonist (Narcan)
(Figure out doses before hand, don’t draw up but be ready)
Flumazenil (Romazicon)
   Classification: Benzodiazepine antagonist
   Action: reverse the effects of procedural sedation and
    reverses paradoxical reaction
    ◦   Neonates: IV 2-10 mcg/kg every minute times 3 doses
    ◦   Children: Initial dose: IV: 0.01 mg/kg, max initial dose 0.2
    ◦   Repeat doses: 0.0005-0.01 mg/kg (max 0.2 mg repeated at 1
        minute intervals
    ◦   Max total dose: 1 mg or 0.05 mg/kg (which ever is lower)
Naloxone (Narcan)
   Classification: Narcotic antagonist
   Uses: narcotic overdose, post-operative narcotic
   Dosing
       Neonate: 0.1 mg/kg/dose
       Children IM/IV/SC: 0.01 -0.1 mg/kg
          May repeat dose every 2-3 minutes (max dose is 2
Allergic Reactions
   Nursing alert: If procedure involves infusion of a contrast
    material – watch for allergic reaction
   Hives, rash, flushing, uticaria, laryngeal edema, hypotension
   Benadryl would be the drug of choice for an allergic
   Paradoxical reaction to versed
Post-Procedural Management
Post-Procedural Monitoring

    Parameters and accompanying timeframes:
        Monitor every 15 minutes post-procedure until:
          child sips clear fluids
          child returns to prior mobility status
          Child returns to within 2 points of pre-procedural
           Aldretti score
Post-Procedural Monitoring

   Parameters and accompanying timeframes:
       Monitor continuously if:
           child has history of cardiac or respiratory disease
           Excessive sedation used
           Vital sign instability
           O2 desaturation during procedure
       If reversal agent used
           Recovery assessment must continue for 2 hours following the
            final dose; reversal agents may not outlast sed/opioid drug effects.
        - ―Emergence phenomena‖
Monitoring Discharge Criteria
   The following discharge criteria should be included, but not
    limited to:
          -adequate respiratory function
          -stability of vital signs
          -preoperative level of consciousness
          -intact protective reflexes
          -return of motor/sensory control
          -absence of protracted nausea
          -adequate state of hydration
Outpatient Considerations

   All outpatients must receive post-sedation
    precautions and be discharged from the area
   Written instructions must include:
       Post procedural complications
       Activity limitations
       Bathing instructions
       Plan for follow-up care:
           Emergency numbers
           Next physician appointment date

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